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F, 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 N611862 for well/pum1and the Rules and Regulations of the San Joaquin , <br /> Local Health District. 11117 'P �lJ <br /> • �Q� / /�fCity Size PM <br /> Job Address ` - - <br /> °-A14PAddress Phone <br /> Owner's Name /� <br /> Address <br /> `� Aw License No•��Phone <br /> Contractor <br /> TYPE OF WELL/.PUMP: NEW WELL ❑ WELL.REPLACEMENT EJ DESTRUCTION LJ } <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 'DISTANCE.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IN USE TYPE OF WELL"-' PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑'Industrial ❑ OP- <br /> enr96ttom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> y <br /> Specifications 93 <br /> ❑ Domestic/Private- � Type of Casing <br /> Pack ❑ Tracy g <br /> M Public ❑ Other n Delta Depth of Grout Seal Type of Grout i <br /> l'1 irrigation —,.Approx. Depth l I Eastern Surface Seal Installed by - M <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 l <br /> Depth Filler Material (Below 501 <br /> REPAIR/ADDITION l ] DESTRUCTION l I (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION <br /> � ;.� available within 200 feet.) <br /> J' <br /> Installation will serve: Residence— Commercial= Other <br /> Number of living units: Number of bedyooms a ` <br /> Character of soil to a depth of 3 feet: L Water table depth <br /> SEPTIC TANK Type/Mf pacity�o& No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> " Distance to nearest: Well Foundation�_.__ Property.Line ' <br /> LEACHING LINE Jk No. & Length of lines Total length/size = <br /> r � <br /> FILTER BED 1-1Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size _ Number <br /> SUMPS L� Distance to nearest: Well Foundation_���, Property Line <br /> DISPOSAL PONDS ❑ � <br /> 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. N -, g - <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the-performance-of-the work for wfiiali this parmit.is issued, I shall not a <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,i shall employ persons subject to workman's corriperisa- <br /> tion laws of California." <br /> The applicant must call or II required inspections. Complete drawing on r`eJerse side.; } { 1 l <br /> Signed X -Tile: <br /> f.C//'2' �* ' Date: <br /> eOR DEPARTMENT USE ONLY F 1 <br /> t Application Accepted by Date Area <br /> r s Date <br /> Final,inspection <br /> Pit or Grout Inspection by Date ` f byY' ' M <br /> .�T <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca' 823-7104" ElTracy 835-6385 4" <br /> k Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 �' . <br /> r <br /> FEE FAMOUNTDUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> r.EH 14-24 iREV.tiK51 <br />