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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin i <br /> Local Health District.- ip <br /> Job Address City ` Lot Size PM <br /> Owner's Namet7� q Address �r7 Phone <br /> Contractor A697V � Address -�3 f�l'4 Licen? No. �a I Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CIPUMP INSTALLATION Cl SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTA CEPT,O NEAREST: SEPTIC �ANK SEWER LINES ��6lSPOS FLD. PROP. LINE \ <br /> FOUNDATION \ __ AGRICULTURE WELL OTHER 'ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 4 PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well/txcavation! 1 - xvDia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1' +� "IeSpecifirations <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal —'`___ Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Su ace Seal Installed by s+ p� } <br /> Repair Work Done ❑ Type of Pump H.P. e State Work Done 1 <br /> Well Destruction ❑ Well Diameter Sealing haterial {top 501 <br /> Depth `Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ADDITION)< DE;STRUCTIOI� ❑ ( o septic system permitted if public sewer is <br /> a l'ilable within 200 feet.) <br /> Installation will serve: Residence_ Commercial_/Other" Z i <br /> Number of living units: Number of bedrooms/ <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ! No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest, Well Foundation Property Line - -= <br /> i <br /> LEACHING LINE j2-"No. & Length of Lines Total length/size 40 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Dept Size 33 /T1`,,,' Number <br /> SUMPS ❑ Distance to nearest: Well /11 Foundation 2O~ Z p� <br /> Property Line <br /> DISPOSAL PONDS ❑ I <br /> 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 Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this'permit is issued, 1 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 following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applicant must ca quir inspec' Complete drawing on reverse side. ' <br /> Signed X Title: / 9iY �7Z Date: <br /> FOR ARTMENT USE ONLY / <br /> Application Accepted y Date - _ Area Q r <br /> Pit or Grout Ins pecti A y� Date Z Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy►�8354M� <br /> L <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + Eli 13-24MEV.1/a5) �—]'�+ «� _�X9 S "_1 <br /> EH 14-28 r <br />