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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 -� <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED I vV <br /> (Complete in Triplicate) + <br /> 1_ y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descri s app kation is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and in desctio oaf San Joaquin <br /> Local Health District. BB I <br /> Job Address/5 -g <br /> Cit C Lot Size 0 3 PM t <br /> i <br /> Owner's Name r Address �_� !/ C�lr} — .�� Phone <br /> N <br /> Contractor Address License No. <br /> Phone <br /> YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA N ❑ SYSTEM REPAIR- OTHER ❑ <br /> DISTANCE TO NEAREST. SEPTIC'TANK SEWER LINES DISPOSAL FLD. PROP, LINE I <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTR TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> ell Excavation Dia. of Well Casing ' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e o ing <br /> Specifications <br /> f'l Public f� Other F1 Deita Depth of Grout ! s <br /> Type of Grout <br /> I i Irrigation -Approx. Depth I J Eastern Surface Seal Installed <br /> Repair Work Done ❑ Type of Pump P. State Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ Ar 1'AIR/ADDITION 1.1 DESTRUCTIO INo septic system p muted if public sewer is ' <br /> available within 200 feet.) \. <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: <br /> SEPTIC TANK Ll Water table depth Type/Mfg Capacity . Water <br /> r <br /> PKG- TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation -Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L-i Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 3 <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 /> 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 California." <br /> .j <br /> he applicant must call for all required inspections. Complete drawing on reverse side. <br /> J/ / <br />' Signed X /r/�. .;. <br /> Title: ' Date: <br /> FOR T USE ONLY <br /> Application Accepted by <br /> Date Area F <br /> Pit or Grout Inspection by Date Final Inspection by <br /> r Date <br /> Additional Commants; ed • pi+ w, : e,,,, <br /> ❑ Stk 4§5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Ap ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - - r <br /> FEE <br /> I <br /> INF MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 124(REV.i/n 51 <br /> EH 14-4-2tS JJJ <br />