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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 <br /> Local Health District. <br /> _ � f <br /> Job Address T - City Lot Size PM <br /> 1 <br /> Owner's Name Address Phone <br /> Contractor i Address �� � License No. 0� Phone 15S� <br /> TYPE PF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER LJ a <br /> l <br /> DISTANCE TO NEAREST: SEPTIC,7ANK' SEWER LINES r DISPOSAL FLO. PROP: LINE <br /> FOUNDATION AGRICULTURE WELLI OTHER WELL PITSISUMPS 3 <br /> INTENDED USE i —TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ` ❑ Open Bottor-ri ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/-Private ❑ Gravel Pack ❑fir car y Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth.of Grout Seal Type of Grout ! _ <br /> _ I I Irrigation... �_Approx. Depth I I Eastern Surface Seal Installad-by- <br /> Repairs Work Done ❑ Type of Pump H.P. -------- State Wo Done= i. <br /> Well Destruction D Well Diameter _1� Sealing Material (top <br /> Depth '" Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:a NEW INSTALLATION REPAIR/ADDITION-IJ—DESTRUCTION-1-1-(No.seplic.system-pormitted if public sewer'is <br /> available within 200 feet.) <br /> Installation+will serve: Residence A'- Commercial_ OtheriZ <br /> I #� <br /> Number of living units: Number of bedrooms f,+1` � <br /> Water table <br /> Gha acter.of_soil to a depth of 3,feet; "�" f. depth <br /> SEPTIC TANK i ❑ Typel"Mfg __ Capacity Noy Compartments t <br /> PKG. TREATMENT PLT.D � Method of Disposal <br />}' 3 ; _ d. _ �. ! oundation _ P s - <br /> f , - Distance,to nearest_: Vhlell '"'- ."� P 4p ty_-Line 3 <br /> t. 1T <br /> l LEACHING LINE '}rd''-No. & Length of lines - Y~ F 'Totall length/size D <br /> FILTER BED ", �' D-, Distance to nearest: Well� Foundation / Property Line 3 _ ' <br /> f r <br /> f SEEPAGE PITS V) Depth _ /6 -'T Size 3C r Number <br /> SUMPS ray`Distance to nearest: Well �Fo nu Pro <br /> dation perty"Line Ire <br /> DISPOSAL PONDS ❑ �""= $ fi <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 /> Homeowner or 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 torbecome subject.toaworkman's compensation laws of California." Contractor's hiring or sub-contracting signature,, <br /> certifies the following: "I certify that in the perfoemance of the work for which this.permit is issued,I shall employ persons subject to workman's comperisa' <br /> tion laws of California!" j ; 4l <br /> The applicant must call for alt-required inspections Complete drawing on reverse side. C" <br /> fid <br /> Signed X Title: �"� Date: �! •-c <br /> k f FOR DEPARTMENT USE ONLY ` <br /> i Application Accepted'by' Date Area <br /> y"'. • <br /> Pit or Grout Inspection by Date Final Inspection by Date .t / <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> i Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> ,..FEE _ -r� <br /> AIuIDUNT DOES' _ ANI4LJIVT_REMITTEI]„�T" CK REa1VED-8Y, - C0)ATE��-" PERMI7••i en-� <br /> INFO. _ ­CASH <br /> �jM. <br /> + EH 13-241REV.I/x53 �O `'- . > s �^� <br /> Eri,.- �a-3a��. =yAB <br />