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APPLICATION FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA y <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 /> 0,`� City S, Lot Size <br /> PM <br /> Job Address <br /> ddress Phone <br /> Owner's Name f,- <br /> �— (._,� A_dd_ress _� License No. Phone ak_ r <br /> Contractor_.�..-sss.-... - — <br /> TYPE OF WELL/PUMP: NEW WELL LJ <br /> REPLACEMENT ED DESTRUCTION LJ <br /> "PUMP INSTALLATION LISYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL RD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS O <br /> ❑ Industrial ❑ Open Bottom d:❑ Manteca' Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f 1 Public ❑ Other ~Delta Depih of'Grout Seal Type of Grout <br /> I I Irrigation __..Approx. Depth I I Eastern Surface.Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P.- i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> Depth Filler Material {Bdow 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (L4STRUCTION 5fiNo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence_ Commercial�6ther <br /> f <br /> Number of living units: Numberfof bedrooms <br /> Character of soil to a depth of 3 feet: �!,i w//-~�� _ _ _U, ' Water table depth <br /> SEPTIC TANK N�- Fype/Mfg Capacity I .No. Compartments <br /> t Method of Disposal <br /> PKG. TREATMENT PLT..❑ �'� ' <br /> 3 c. ria► s - .._ <br /> t <br /> Distance to nearest: Well �— Foundation Pro pert Y Line <br /> 4rI L <br /> rLEACHING LINE:,f wf O'fNo'. & Length of lines F Total length/size <br /> f - - <br /> FILTER BED ❑ Distance to pearest: Well:�^^ I Foundation Property Line <br /> f.1 t 4 s <br /> SEEPAGE PITS 4 Tl I _Depth site Number <br /> I, SUMPS Ll Distance to nearest: Wells Foundation Property Line <br /> DISPOSAL PONDS " ❑ } Y ' ` J } <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, 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 /> F certif• he following: " 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 o alifornia" s <br /> The applica t uGtUA'Al,red 1 ctio pieta drawing o everse sid o—� <br /> Signe = Title: Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by <br /> � Date <br /> l Pit or Grout Inspection by Date Final inspection by Data <br /> I Additional Comments: = �� <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 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 /> r � ) <br /> PEETAMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. <br /> )NFOj� a+.EH 13-24IREV.S/H5) 0 �f C YL l-JO � �EH 14-2e - <br />