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t . <br /> APPLICATION FOR PERMIT <br /> IA ` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address x 3 ?`O d ArThy Y /7CJ►� City 4XGA L oN Lot Size PM <br /> Owner's Name 64fyPy She 4 Tc* Address Phone <br /> Contractor Address �d3. ✓� ✓� �� License No. 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 OTH�R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> Cj <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public ❑ Other ❑ Delta Depth-of Grout Seal Type of Grout_—_ <br /> I I Irrigation __.Approx. Depth I I Eastern rSurface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P., State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 N <br /> Depth Filler Material (Below 501 —_ C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AREPAIR/ADDITION 1_1_1EaJBILCtTION I I (No septic system permitted if public sewer is <br /> i`' available within 200 feet.) <br /> Installation will serve: Residence J— Commercial_ Other Jr <br /> Number of living units: __/_ Number of bedrooms <br /> Character of soil tA*pth of 3 feet: AflivepAw - Water table depth <br /> SEPTIC TANK �1••Type/Mfg 1Ps0 C.RftT Capacity{ 6CZ0 1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ �' .✓„y`4 Merhad of Disposal <br /> Distan'be to nearest: Well@�� Foundation 4W­ Property-Line*O <br /> s <br /> LEACHING LINE QI No. & Length oUlines 3' yo x Total len th/size f z <br /> FILTER BED ❑ Distance to nearest:' Well /O� z Foundation „+'F ' iVN' roperty Line <br /> SEEPAGE PITS I I Depth Size 1K-417 �`/�� Number -3 ' <br /> SUMPS ItT Distance to nearest: Well- <br /> oundation roperty Line �0 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be,done in accordance wi h San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. .i.. I <br /> Home owner or licensed agent's signature certifies the following: _ <br /> g g g: "I certify that in th'e,;performance of the work fol Which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation lawsIof Californla,"Con(raC or's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permi is Issued I shall employ rL4s subject to workman's compensa- <br /> tion laws of California." ._ } ti <br /> The applicant mus call for all required inspections. Complete drawing on reverse Side. `•, r,,.� <br /> , l! <br /> Signed X Title: Date: <br /> 77FORBIPARTWNT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED H ,RECEIVED BY `/DATE PERMIT' <br /> NO. <br /> EH 14-281REV.iix5) O ' ( •� ' ('� 1�/7,Q3 <br />