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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,5 1601 E. HAZETON 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 /> Job Address s ! � ""'� City �/ Lot Size PM <br /> Owner's Name ��Address _� t"/ � _ Phone <br /> Contra&t r-_PO rM Address L License No. 7- one <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.fl DESTRUCTION ❑ ` <br /> 1 z PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ fes. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> rf FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE <br /> _O _WetL- --RBQBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial' ❑ Open Bottom"-"—9-Manteca "-"Dia of�tAleA F,Kcavation Dia. of Well Casing <br /> ❑ Domestic/Private 1 ❑ Gravel Pack ❑ Tracy ,-,, Ty -of Casing� Spee�fications.� <br /> 1`1 Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation J _Approx. Depth I I Eastern y i Surface Seal Installed by _ <br /> Repair Work Dofte ff❑ Type of Pump y'°, H.P. ^ State Work Done <br /> Well Destruction f �❑ Wel! Diameter a ? AY A, Saing Material atop 501 4� <br /> t f Depth Filler'Material {Below 50') 1 <br /> TYPE OF SEPI IC'WORK: NEW INSTALLATION REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> I S / available within 200 feet.) Q <br /> Installation will serve: Residence_r Commercial_;ether e� W <br /> Number of living units: Number of.be±rooms <br /> Characterfof soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK! ,Type/Mfg Capacity- No. Compartments <br /> PKG. TREATMENT PLT`T❑ T �� '� 1 Method of Disposal <br /> �. Distance to nearest: Well rr,Foundatian 'Property Line <br /> LEACHING LINE ❑ No. &L ngth'of lines __'' .*.I length/size <br /> FILTER BED ❑ Distance to.nearesul. Well Founr ation /�f .. Property Line <br /> SEEPAGE PITS 11 <br /> Depth. �' Z' Size or"'rA�1./'� . ��` b � <br /> SUMPS { - Distance to nearest: Well 1� -foundation P operty'Line <br /> DISPOSAL PONDS ❑ <br /> -1 hereby certify that I have prepared this application and that the-wor"ill-�done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I ' 11 <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 subcontracting signature <br /> certifies the following: "1:certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workma 's compensa- <br /> tion laws of Califor ' ."l i <br /> The applicant st 11 for l-requirpd inspections. Cfompiete drawing on r e se side. <br /> Signed X Title: Date: <br /> 1 t k FOR DEPA ENTUSE ONLY <br /> z� <br /> Application Acc tad by Date r Area <br /> Pit or Grout fiction by Date t Final Inspection by 1r Date7 <br /> Additional/Comments: <br /> ❑ Stk 66.6781 ❑ Lei i3693624---- -❑ Manteca 823-7104 ❑ Tracy 835-63B5 <br /> Applicant- Return all copies to: Environmental Health Perrrmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I [CASH RECEIVED BY DATE PERMIT NO. <br /> INFO r <br /> *.EH 13-241HEV.r/H5f <br /> EH 14-2a <br />