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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 P <br /> (Complete ih.Triplicate) a _ . <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 Ryles and Regulations of the San Joaquin <br /> i Local Health District. �`' u <br /> Job Address _qqt� ' <br /> City of Size PM p <br /> Owner's Nam Address Ac <br /> cer <br /> Phone <br /> Contractor Address ! rise No. (6F Phone <br /> n 17 <br /> TYPE OF WELL/PUMP: �I' NEW WELL ❑ WELL REPLACEMENT ❑ <br /> p R DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ A . SYSTEM REPAIR e!�" - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ,w <br /> - —FOUNDATION AGRICULTURE WELL ' OTHER WELL - =""PITS/SUMPS="` - <br /> INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 45'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public , �Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �—,Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type bf Pump H.P. `t _ - �, r.h <br /> r State rk Done <br /> Well Destruction ❑ Well Diameter t Sealing Material Stop 50') <br /> Depth Filler Material (Below 50') �r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El DESTRUCTION (No septic system permitted if public sewer is <br /> -y ---- -- <br /> --available within 200 feet.I S <br /> Installation will serve: Residence Commercial �--Other <br /> Number of living units: %J Number of bedrooms i <br /> Character of soil to a depth of 3 feet: ,.r� Y Water table depth <br /> SEPTIC TANK L01TypelMfg - Capacity 'No. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line ' <br /> LEACHING LINE ❑ NJ,& Length of lines '� Total length/size ._ ' I <br /> FILTER BED ❑ Distance to nearest: Well.— Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation. <br /> _ Property Llne_ _ <br /> DISPOSAL.PONDS ❑ . ��... ___ r 4_, � __ - �-W <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 r <br /> rules and regulations of the San Joaquin Local Health District. 111 <br /> Home owner or licensed agent's signature certifies the following: "I certfy that in the performance of the work for which this permit is issued, I shall not 7 <br /> employ any person in such manner as to become subject to workman'seompensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify tliat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's co...... - <br /> tion laws of California." <br /> The applicant st II for required inspections. Complete drawing on rse side. <br /> Signed <br /> Title: Date: <br /> R DEPARTME T USE ONLY <br /> i <br /> Application,Accepted by ��✓ Date�� oy Area <br /> Pit or Grout Inspection b F�_ 7— <br /> Additional <br /> Y Date Final Inspection by Date.. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 p.a j O <br /> ... <br /> Applicant-'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA,95201FEE <br /> •-•y �:I". <br /> a _ <br /> INFO AMOUNT <br /> .�DUE ` AMOUNT REMITTED5 RECEIVED BY -DATE ,Y,` PERMIT WO. ' <br /> r EH14-26 3241REV.7/B5) qI `� <br /> EH 1Ip � Q� ^•- FS5-�C <br />