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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I 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 /> Job Address CtJy City 665n Cot Size <br /> Owner's Name-, <br /> .Address S_�$���S' � Phone • <br /> Contract r 14Kf' ddress License No. Phone r h� <br /> TYPE OF WELL/PUMP: il N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> _, .-_,,,,PUMP.INSTALLATiON ❑ � SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK Y `"` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ` Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal.' h 3 Type of Grout <br /> ❑ Irrigation J4pprox. Depth ❑ Eastern Surface Sedinstalled by <br /> Repair Work Done ❑ Type of'Pump <br /> H.P. + ± State,Work Done t� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (BelowP <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is ' <br /> ,� available within 200 feet.) o <br /> Installation will serve: Residence� Commercial— Other <br /> Number of living units:_./_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: ! Water table depth <br /> SEPTIC TANK I _ ❑T e/Mf j <br /> i <br /> Yp 9 -- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } } Method of Disposal <br /> _Distance,to nearest:., e�!Well ."~ Foundation Property Line <br /> LEACHING LiNE 14�- No. & Len th of lines'- s ^' .. <br /> 9 � Tota! length/size � <br /> FILTER BED ❑ Distance#to nearest:, Well Foundation Property Line <br /> i <br /> SEEPAGE PITS Depth J_N f_$ize Number__ f <br /> SUMPSp--Distance:to nearest: Well Foundatio' <br /> �—""� y[,�� rt�`l� Property Line <br /> DISPOSAL PONDS ❑ <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 j. <br /> „rules and regulations of the San Joaquin Local Health District. 1, 'J. r A21. <br /> Home owner or licensed agent's signature certifies the following: "I.certify that in the perfbrmance of the work for which this permit is issued, I shall not I <br /> employ any person in such manner as to become subject to workman's compensation laws of California:"ClintracToi s'hiring or`su�corit�actirig'sigriature <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 C ifornia-" 1. 14% 1 <br /> The applica must call for allre 'e ins ctions.�plete.drawing on reverse side. <br /> Signed T ;Title:, Waz Date: € <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by date ' (� Area <br /> Pit or Grout Inspection by + Date 3- Final In 7 <br /> `-��� Inspection by •� Date <br /> Additional Comments: L . . <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 U0 Manteca =7104' ❑ Tracy i <br /> Applicant - Return all copies to: Environmental Health Permitl5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE + <br /> INFO AMOUNT DUE AMOUNT REMITTED'.;: CASH CK RECEIVED BY DATE PERMIT`NO. <br /> + EH 13-24(REV. , <br /> EH 14-29 Cj�I �(� `1^� <br />