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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED . <br /> AComplete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> J$b Address as`/a a a� /' �`�� City Lot Size PM <br /> lafwner's Name Address � � Phone M <br /> f r �ry, 3 License No. �G Phon <br /> Contractor +� o /� Address 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR EI OTHER C] <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER;WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation f Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications <br /> MPublic C1 Other 171Delta Depth of Grout Seal t Type of Grout ck <br /> is I I Irrigation <br /> —Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P. Statey Work Done <br /> Well Destruction ❑ Welt Diameter Sealing Material Itop 501 <br /> Depth Filler Material 18elow 501 <br /> TYPE"OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION t II INailabptic system <br /> m permitted if public sewer is <br /> m <br /> Installation will serye: Residence Commercial Other <br /> Number of living units: umber of be , ms <br /> Character of soil to a depth of 3 feet.. �T Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CQ� <br /> O ,- ,` '-Capacity Zf No. Compartments 7— <br /> Method of Disposal <br /> � <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Welll eProperty.Line '~� r►� <br /> $ M <br /> e LEACHING LINE No. & Length of lines Total length/size d <br /> FILTER BED U Distance to nearest:' Foundation== �Property tine "y <br /> SEEPAGE PITS]°ti; Depth /Z t Size ' Nopbe► p (, <br /> ` Property Line <br /> SUMPS 1"`, ,. __❑,.,..Distance to nearest: Well sFoundation <br /> DISPOSAL PONDS ❑ #: <br /> -a� I hereby certify that I have prepared-this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local HealtFi D§trict. <br /> Home ownerFou:licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject-to-wofkman's•compensation-laws of California."Contractor's hiring or sub contracting signature <br /> ?` certifies the following', I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Calif ni <br />` The applican s all fo require ins ecti plate drawing on reverse side. <br /> 1 <br /> [V i s <br /> Signed X Title-\— Date: <br /> F, DEPARTMENT USE O LY ref f <br /> Application Accepted by Date` Area <br /> Pit or Grout Inspection by �� Date Final Inspection V. <br /> € Date <br /> Additional Comments: ,&7' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 <br /> Applicant-,Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: Box 2009, Stk., CA 95201 <br /> CK 0 <br /> I IE FO AMOUNT DUES AMOUNT REMITTED CASH RECEIVED BY; DATE PERMIT''NO. <br /> •.EH13-241Rt:V.1/x51 0.�� $ FJ /f✓ <br /> F EH 14.26 f <br /> i <br />