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' \Fl APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 1V" JY�1 <br /> Telephone (209) 466-6781 ' '6-AJ- <br /> r <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED W� lir <br />€ (Complete in Triplicate) O k ' <br /> Application is hereby made to the San Joaquin Local Health:District for a permit to construct and/or install the work herein+scribed. This asr"'t-onpIs <br /> made H 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 <br /> City Lot Size" PM <br /> Owner's Namei <br /> Addr <br /> i1�one �!a I I <br /> Contractor dress �5G � <br /> _ License fVo. r9 Phone 7 r� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ° PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION.. — AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDEDUSETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial I D Open Bottom ❑ Manteca Dia. of Well Excavation ---pia. of Well Casing <br /> [D Domestic/Private- ❑ Gravel Pack ❑ Tracy Type of Casing f Specifications <br /> d F] Public t-- [=)'Other -- n Delta +.."Depth-of Grout SealType of Grout R 1 <br /> !i I Irrigation ► ---Approx. Depth I ) Eastern Surface Seal Installed by V <br /> Repair Work Done CJ Type of Pump <br /> H.P." " State Work Done _ <br /> E Well Destruction ❑ Well Diameter -Sealing"Material (top 50'1 <br /> ` Depth Filler Material ii elow 50'),' 1 �- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION t I DESTRUCTION fNo``septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:'Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms } <br /> Character of"soil to a depth of 3 feet: l <br /> Water table depth <br /> i. <br /> SEPTIC TANK - -1-1 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑_ Method of Disposal <br /> l Distance to nearest: Well" Foundation Property Line <br /> LEACHING LINE D No. Length of lines T a! length/size <br /> FILTER BED f ❑ Distance to nearest: Well Foundation Property line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest:.„"" 'WeII'!t'Fouhdation "-- _ 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 L_ocal 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 must cal ctions. Complete drawing on reverse side. q�J <br /> Signed Title: Date: U t?f <br /> f <br /> F <br /> D RTMENT USE ONI <br /> f LY i. <br /> " Application Accepted by 4A Data Area <br /> 1 <br /> Pit or Grout Inspection by ea-�L'` Dates �� J u�� 4-6 C"- ? <br /> Final Inspection by Date <br /> Additional Comments: ,. <br /> ❑ Stk 466.6781 ❑ Lodi 364 3621 ❑ Manteca 823-7104 D 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 /> f <br /> FEE MCASH <br /> OUNT DUE AMOUNT REMITTED CK <br /> INFO RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24)REV.)/x 5) /+ <br />