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r <br /> APPLICATION FOR PERMIT V9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEbo' �`°" ' <br /> � ) '} <br /> . � J�--„� K,? �y- (Complete InTriplicate) �CS Application is hereby made to thn <br /> an? <br /> Local Health District for 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 R les and Regulations of the San Joaquin <br /> j Local Health District. <br /> Job Address ` S - - <br /> .. .r . . , . .- City <br /> 5AZ'0C kTIF ot Sze� 4 y.��. <br /> ' <br /> l <br /> PM <br /> -Owner's Name C9 _ -AddressPhone tD l <br /> 4� ��s <br /> Contractor + Address License No. Phone <br />` TYPE OF WELL/PUMP: NEW W WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `` _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> E <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 9 <br /> domestic/Private —ravel Pack ❑ Tracy Type of Casing Specifications ' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> YP VZO <br /> - <br /> ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filter Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence IL Commercial_ Other - <br /> f�E. <br /> Number of living units:—I— Number of bedrooms. E <br /> rte , <br /> Character of soil to a depth of 3 feet:_ Water table depth e <br /> SEPTIC TANK Type/Mfg Capacity_ 1 oO 91 No. Compartments CCJ ® T a <br /> PKG. TREATMENT PLT. ❑ ' Method of Disposal fi <br /> Distance to nearest:dt Well_ -z Foundation <br /> .* Property Line <br /> "ALEACHING LINENo. & Length of Lines _F t' f" Total length/size— - (,�-r <br /> FILTER BED Distance to nearest: We: T Foundation�G _L Property Line <br /> SEEPAGE PITS 0!�, Depth Size -� i <br /> Number. . <br /> SUMPS ❑ Distance to nearest: i^ Well d " Foundation <br /> 1 I- � �Property Line I O IF <br /> DISPOSAL PONDS ❑ r, <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 a <br /> rules and regulations of the San Joaquin Local Health District. t ! <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 /> i <br /> The appficantwust call f r II require inspections. Complete drawing on reverse side. ;J <br /> Signed Title; Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> f p� <br /> Pit or Grout Inspection by Date Firial lnspecti by Date V , <br /> Additional Comments: r , t <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.,gA.96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ;A(-.CK <br /> INFO RECEIVED-BY-- -DATE. <br /> + EH1426 <br /> 3-241REV,i/s51 - - � �`'S U 00 <br /> q- b"�`6 <br /> EH 1 `""'••++�.... •..- { i"� <br />