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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., <br /> STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES"f YEAR FROM DATE ISSUED <br /> A.: �'_• (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 incompliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District <br /> Job Address 1 t ! F'� y.w �t ,. City f :;" ;';Lot Size PM <br /> Owner's Name <br /> { Phone <br /> Contractor 1 `,, -. s �z r ,',; P�. .� Address r/ r i; li, s *r y , •• :,e <br /> r !�., r .:. u •. %L-icense No. l :I Phone ,.=•f.'f ;' .�,. . <br /> TYPE OF WEglPUMP:tNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 5, <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS j <br /> _JNTENDEO USE r TYPEOF'WELL ;-PROBLEMAREA`' CONSTRUCTION SPECIFICATIONS <br /> I ry❑ <br /> industrial­',',­ <br /> ndustrial P,Open Bottom -:J..0-Manteca_. _ a_Dia. of Well.Excavation Dia:of Well Casing <br /> Cl Domestic/Private q Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I <br /> r"1 Public n Other T [� Delta Depth'of Grout Seal Type of Grout <br /> "A, Irrigation —Approx. Depth . I I Eastern Surface Seal Installed,by ' <br /> Repair Work Done ❑ Type of Pum <br /> Q P YP P H.P. State Work Dane_,•_ <br /> ction` _ <br /> Well Diameter <br /> Sealing Material Itop 50'1 <br /> Well Destru <br /> Depth _ Filler Material {Below 501 "••. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION 1:1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> y available within 200 feet.) <br /> Installation will serve k 'Residence___a Commercial Other -it # <br /> Number,of It+ring units: „Number of bedrogins * ' <br /> Character of soil to a depth of 3 feev., } Water table depth <br /> t} SEPTIC TANK 0,?' Type/Mfg ' *' Capacity No. Compartments J <br /> PKG. TREATMENT PLT.❑ ii Method of Disposal <br /> ? '{ Distance to nearest: Well Foundation Property.Line <br /> ,.." <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 Deptli Size_ Number <br /> SUMPS 0. Distarice to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 3 ' <br /> hereb certrf"that I have prepared this application and that the work wrll be;done'in accordance with San Joaquin county ordinances, state laws, and <br /> Y.,. Y. P p PP. <br /> rufeS and regulations af_the San Joaquin Local.Health-District. <br /> Home ovjrner or licensed agent's signature certifies the fallowing '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 es to become subject to workman's compensation taws.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, l shall employ persons subject to workman's compensa- <br /> tion taws:of.California." ' <br /> The applicant must call for allrequired inspections. Complete drawing on averse side. <br /> '� �+ f <br /> Signed Title:(' J ,* �. :._ Date:­. ofL' <br /> FOR DEPARTMENT USE ONLY <br /> ;. Application Accepted by f rf Date + Area <br /> E <br /> t r Grout Inspection b e Final Inspeclian b Date/ ` <br /> t <br /> f Additional Comments: - <br /> ❑ Stk 466.6781 ❑ EodiqX21... . Manteca 823-710# ❑ 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 /> CK 0 <br /> INFO FEE "AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> -.EH 13,24IREV:1/X51 <br /> EH 1428 <br />