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APPLICATION FOR PERMIT <br /> w I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'I 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I! Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I - (Complete in Triplicate) <br /> il <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> f Local Health District. <br /> I F. <br /> Lot tYs"'�'' Size PM <br /> Job Address%"7 / 1 L� Ci <br /> Owner's Name 4 0�1 h it Address Phone <br /> Contractor <br /> Address License No. Phone <br /> TYPEContract <br /> W LlPUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION El <br /> - - PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER El V \` <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 i ❑ Open Bottom 171 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> + ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ` <br /> ❑ Public ❑ Other ! ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation I _—Approxi Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump. .. H.P. State Work Done . <br /> Well Destruction. ❑ Well Diameter .te Sealing Material (top 50'1 <br /> Q <br /> Depth w'r� Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLA ION ❑ REPAIR/ADDITION LJDESTRUCTION El (Noilabseptile sy tem emitted if public sewer is ` <br /> j 4 \ <br /> Installation will serve: Residence� Commercial_ Other <br /> t Number of living units:J__ Number of b 'r ms .— <br /> Character of soil to a depth 3 feet: Water table depth <br /> SEPTIC TANK .L�f Type/Mfg Capacity No. Compartments <br /> Method of Disp sal <br /> PKG. TREATMENT PLT. ❑ <br /> k ' Distance to nearest: Well y Foundation_.� Property Line <br /> LEACHING LINE ❑ No. & Length of lines 2 /Total Length/size / <br /> FILTER BED ❑ Distance to nearest: ,Well�EdL Foundation� Property Line- <br /> SEEPAGE <br /> ineSEEPAGE PITS I] Depth ?.Size Nymber <br /> SUMPSDistance to nearest: Well lam; Foundation ll Property Line <br /> DISPOSAL PONDS . 0-- <br /> d that-the work will be done in accordance with San Joaquin ordinances, state laws,and <br /> I hereby certify that 1 have prepared this application an <br /> rules and regulations of the San Joaquin Local Health District.. <br /> Home owner or licensed agent's signature certifies the followingr."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 workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the f ing: certify that the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws Calif rni .i <br /> ` The app ant us a a r uired inspections. Complete drawing on reverse side. i <br /> t r�l�r�r,r.� <. <br /> Signed + Title: _Date: <br /> FOR DEPARTMENT USE ONLY <br /> E Date `L Area <br /> Application Accepted by ' - <br /> i <br /> Pit or Grout Inspection by y ate Final Inspection by Date <br /> 3 # <br /> Additional Comments: 's i <br /> ❑ Stk 466-67$1 ,_„ ❑ Lodi -369-3621 x ❑ Manteca 823-7104 „❑ Tracy 835-63M t <br /> Applicant- Return'all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I Al <br /> IrFE NFO AMOUNT DUE AMOUNT REMITTED CASWRECEIVED BY GATE PERMIT'NO. <br /> +EH 13-241REV.1/85i �I �. 7o, ,c,- <br /> EH 14-28 <br />