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i <br /> ,r <br /> APPLICATION FOR PERMIT ' -3 u <br /> - SAN JOAO.UIN LOCAL HEALTH DISTRICT slad ■L® <br /> 1601 E. HAZELTON-AVE., STOCKTON, CA <br /> Telephone (209) 460-6781 <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 �.'�� � + l� City 15°ti Lot Size PM <br /> Owner's Name ddress / 1 Phone <br /> Contractor's Name License No. --7- ' Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ i W41-RE LA EMENT ❑ i DESTRUCTION ❑ <br /> PUMP INSTAtrATION ❑ 'SYS E. REPAIR ❑ j 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 <br /> ❑ Industrial 0 OpenBottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ 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 Cl Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') �� <br /> Depth Filler Material glow ') ` 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITIO D STRUCTION ❑ (No septic system permitted if public sewer is VD <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other e <br /> Number of living units: Number of bedrooms �1 <br /> Character of soil to a depth of 3 feet: -I IgE Water table depth 14249 <br /> SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line <br /> LEACHING LINE ill- o. & Length of lines O ¢ <br /> 9 l` � Total length/size V <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ Property tine <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 workman's compensa- <br /> tion laws of California. <br /> The applicant mus c for r it d i ctions. Complete drawing onrev se side. <br /> C 7 <br /> Signed � Title: Date: <br /> R DEPARTMIENT USE ONLY <br /> +e <br /> Application Accepted by * Date (� " 1%k �65Arse o q5 <br /> Pit or Grout Inspection by C,� ,� Baa. Date /6-Q,5 Final`Inspe <br /> 1ction by \I�n�. A, .-�o..�o... Date <br /> i <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 /> I <br /> FEE <br /> INFO AMOlU�]N,Tr/D}-UE AMOUNT REMITTED CASH RECEIVED BY DATE ;PERMIVAO. <br /> +EH 13-24(REV.10/83) 1- l 1J [ / 5,<<, Y a3 <br /> EH 14-28 <br />