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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> '�f <br /> r Z kb Cit Lot Size PM <br /> Job Address Y <br /> Owner's Name CTr� 0a-!5 7 Address Phone <br /> Contractor Addressdrli�C/ I � License Na 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 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFWELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other' ❑ Delta 'Depth of Grout Seat Type of Grout <br /> i I Irrigation. __.Approx. Depth I 1 Eastern} Surface Seal Installed by _ <br /> Repair Work Dane ❑ Type of Pump H.P. ' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 V <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION [ I DESTRUCTION I I INo septic system permitted if public sewer is <br /> c: ; available within 200 feet.) <br /> Installation will serve. Residence Commercial_ Other` <br /> Number of living units: —L Number of bedrooms <br /> Character of soil to-a depth of 3 feet: Water table depth ` <br /> SEPTIC TXNK"��`� "cl Type/Mfg P7f�' r Capacity "` No. Compartments <br /> PKC. TREATMENT PLT. ❑ —FJr s# c�� Method of Disposal <br /> " k Distance to nearest: Well��'v Foundation Property Line <br /> LEACHING LINE 7" No. & Length of lines "' Total length/size d <br /> FILTER BED ❑ Distance to nearest: Well 1414 Foundation F7' Property Line <br /> SEEPAGE PITS 11 Depth SizeNumber <br /> •�° ; <br /> SUMPS ❑ Distance to nearest: Well "- Foundation Property Line <br /> DISPOSAL PONDS ❑ as <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 lollowirig:11 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 t&'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 /> d <br />• The applicant. ust call for akl quire inspectio . Cm <br /> oplete drawing on reverse side. <br /> Signed X Title: �'d.. �C/ Date: <br /> t <br />{. <br /> Foh WPARTMENT USE ONLY <br /> Application Accepted by Date — r Area 1,3 <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 AMOUNT DUE AMOUNT REMITTED CK . RECEIVED,,BY DATE PERMIT_NO. <br /> L <br /> INFO-, -C SH..-_ �j 2 .. /_. _... <br /> — - - ^.b ✓ 4 �JIf .— -max <br /> +.EH 13-24 iMZ7,s so <br /> 7 �» <br />��. EH 14-26 <br />