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� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> v Telephone (209) 466-6781 (� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby <br /> 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 Aures and Regulations of the San Joaquin <br /> Local Health District. <br /> /U City Lot Size _ PM <br /> Job Address <br /> 11G CYl. _�1V •" PhoneC <br /> ol <br /> eAddress <br /> Owner's Name i <br /> License No. Phone <br /> Contractor <br /> Address <br /> TYPE OF WELL/PUMP: NEW WELL E] WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> OTHER ❑ <br /> PUMP INSTALLATION 171 SYS <br /> TE REPAIR El 1 <br /> SEWER LINES <br /> DISTANCETONEAREST: SEPTIC TANK <br /> DISPOSAL FLD. "'' ""''". PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> �omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> F1 Public (7 Other <br /> Ll Delta ' Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation ,..Approx. Depth .I I Eastern- Surface-Seat Installed by <br /> H`p. . State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') V' <br /> Depth Filler Material (Below 50') — 90 <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT EPAIR/ADDITION t I DESTRUCTION (Nailsepti cystithin m reined if public sewer is <br /> fInstallation will serve: Residence Com rcial Other ` <br /> Number of living units: --/— Number of bedrooms �...ry <br /> Character of soil to a depth of 3 feet: v Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> .•mx...„—..w... - ---.;":Wt,.w-ter i ` <br /> PKG. TREATMENT PLT;:O ` "�" " f '" .-, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> do <br /> iTotal length/size <br /> LEACHING LINE � ,C! No. & Length of lines � • _ _ r <br /> FILTER BED ,0 Distance to nearest: 'Well T Foundation � Property Line _; <br /> Number <br /> SEEPAGE PITS l I Depth Size — <br /> SUMPS —0 Ll Distance to nearest: Well f -Foundation Property Line ti.1 <br /> r DISPOSAL. PONDS ❑ r I ' <br /> I hereby certify that I have prepared this application.ani.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 Di?;trict. <br /> i 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: 'Tcertify that.in.the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California."' .. <br /> The applicant must call for req u' d inspections. Complete drawing on reverse side. p <br /> ` Date: I Ido <br /> Signed Title: <br /> s. FOR DEPARTMENT USE ONLY <br /> t�Z <br /> Application Accepted by Date Area <br /> if• <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 - ❑ Lodi 369,2621 ❑ 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIY'NO. <br /> INFO �]�/�.(yy} ��jJ <br /> +.EH13-241REV.1/ri51 � ,� ' * 1� +y� '+" ` 7-5I <br /> EH 14-29 <br />