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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Y 1 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. �j. <br /> Job Address 1112 `Q() K � _ R"OL _ City of Size PM <br /> r" , l <br /> Owner's Name Address Phone ~�/ i <br /> Contractor V. Address 470,5'Ir752�`�L.J � _License W Phone <br /> TYPE OF WELL/PUMP` NEW WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION B-*— SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f SEWER LINES DISPOSAL FLD. PROP. LINE ���t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> rl <br /> Industrial pen Bottom El Manteca Dia. of Well Excavati��on��� "" t Dia. of Well Casing <br /> W151Inmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_�,,� :_f Specifications ^° <br /> FI Public n Other ❑ Delta Depth of Grout Seal Type of Grout5&C�? + <br /> I I Irrigation 32.1-0-Approx. Depth, I I Eastern Surface Seal Installed by t I tic _ <br /> Repair Work Done ❑ Type of Pump " H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 't Sealing Material (top 501 <br /> Depth Filler Material (Below 501 �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION I I DESTRUCTION I 1 1No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_. Commercial— Other N) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ? <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property"Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 ` <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 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, t shall employ persons subject to workman's compensa- <br /> tion laws of Californi -__. <br /> The applicant st II for all re wired ifispections. mplete drawing on r ��e_�rsQ sid Q <br /> Signed Tiile: � llU/�'` Date: <br /> ( FOR DEPARTMENT USE ONLY q ` <br /> Application Accepted In Date �� `� 17? \Area <br /> Pit or Grout'Inspection by i 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED 9Y DATE PERMIT NO. <br /> �.EH 13-24(REV.t i H 51 } [^1 / /► �/ /� y <br /> EH 11-28 v (/ ! / <br />