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APPLICATION FOR PERMIT <br /> �4 <br /> SAN JOAQUIN LOCACHEALTH DISTRICT - r <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Joh Address City <br /> C N. Lot Size PM <br /> 5 7 <br /> Owner's Name Address 9��r� I Z 11? Phone <br /> /� <br /> ` Contractor �_YvL� � Address ©� License Nov'�8�5 .L Phone <br /> I 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 z <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTIdl SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom'. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout—.--- <br /> I <br /> rout _I Irrigation _ Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> d <br /> Well Destruction ❑ Well,61ameter Sealing Material {top 50') <br /> Depth!; Filler Material {Below 50') —_ <br /> TYPE OF SEPTIC WORr,: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 200 feet:), <br /> Installaton will serve: Residence Commercial_ Other```'"` <br /> Nurrlber of living units: Number of bedrooms , <br /> Character of soil to a,ydepth of 3 feet: 3+ t Water table depth <br /> SEPTIC"TQNK ' ❑ Type/Mfg P44,i I.CapacityA 4 N: Compartments <br /> PKG.-TREATMENT PLT.❑ ' ,'Method of Disp so al <br /> ' Distance to nearest: Well Foundation_A1e�__ Property Line.=s.,�-.. � <br /> LEACHING LINE 'f No. & Length of lines 'f y ` Total leng_th/size <br /> FILTER BED ❑ Distance to nearest: Well 4QA2 /G <br /> Foundation � " _ <br /> Property,Line,�� . <br /> SEEPAGE PITS I I Depth Size ''r"Number <br /> SUMPS I- Distanceto nearest: Well Foundation �` PrApe`rty L"irie <br /> DISPOSAL PONDS ❑ j <br /> 1 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 Di$trict. <br /> a 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." '. r ? t <br /> The applicant must call for II re Li d inspections. Complete drawing on reverse side. <br /> Signed X Title: ...... ,�i+t�t� t;" ' Date: �ra� <br /> FOR-DEPARTMENT USE ONLY' e <br /> Application Accepted by Date A=il Area <br /> 1 Pit or Grout Inspection by Date Final Inspection by Date , <br /> Additional Comments: r <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, Silk., CA 95201 <br /> f it <br /> FEE <br /> �ffi�rr INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY .r OATE PERMI7�NO'." n" <br /> r +�.EH.13-241REtrr7'liTl <br /> L �' <br />