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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Tripjjcate) <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 7 <br /> Job Address/ /11 eW Z) 6 City f Lot Size :x7 PM <br /> Owner's Name 6 19 C94AAddres. Phone , <br /> Contractor's Name oe,4 %lfell 4 Sellll License No. 2 J Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private 71Gravel Pack ❑ Tracy Type of Casing Specifications L <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 of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Belo 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Ir DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ,s available within 200 feet.) <br /> Installation will serve: Residence !/ Commercial— Other <br /> Number of living units: Af Number of bedrooms�7 <br /> Character of soil to a depth of 3 feet: G Water table depth <br /> SEPTIC TANK Type/Mfg Capacity—/-2-i1Q— No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ s 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 workmen's compensa- <br /> tion laws of California." <br /> The applicant call for all re uired inspe tions. Complete drawing on reverse 'de. <br /> Signed Title: Date: <br /> FOR DEPARTM T USE ONLY � <br /> Application Accepted by Date q — i -7— ? Area <br /> 2 �`6 �V/ <br /> Pit or Grout Inspection by Date Final Inspection by 01. Date <br /> Additional Comments: / — <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> INFO CASH <br /> + EH 13-24(aEV.10183} ` I` 1'�_ � ��17 <br /> if-17-6 <br /> EH 1428 <br />