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UA APPLICATION FOR PERMIT Ai <br /> mw SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.; STOCKTON, CA <br /> A .0 L <br /> Telephone {209} 466-6781 F <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED, <br /> .J. iF9a..:. . (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 <br /> Local Health District: Rules and Regulations of the San Joaquin <br /> Joh Address �� ^ W - <br /> 'City .-.UC IG!`Zv�t Size R PM <br /> Owner's Name Address ` — <br /> W Phone 2 2 L . <br /> Contractor Address License No. Phone <br /> TYPE OF WEL /PUMP: NEW WELL 0 ELREPLACEMENT ❑ DESTRUCTION ❑ <br /> MP CATION ❑ SYSTEM REPAIR ❑ ,, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L�NES DISPOSAL FCD. <br /> PROP. <br /> FOUNDATION, '�- v� <br /> _: 1.--tee: ICUL-TURE WELL. OTHER WE PITS/SUMPS <br /> _ - <br /> INTENDED USE TYPE OF WE PROBLEM R A TRUCTIO IFICATIONS <br /> ❑ Industrial p Open Bottom ❑ Manteca Dia cavation Dia. of II Casing <br /> ❑ Domestic/Private Q Giavel Pac i ❑ Tracy Type of Casing <br /> Specificatiocs <br /> ❑ Public tther .❑ D Depth of Grout Seal Type of Grout <br /> El Irrigation _Approx., est ' Eastern Surface Seal'Installed by <br /> Repair Work Done ❑ Type of Pu H.P. State Work Done <br /> Well Destruction ❑ Wel meterM- <br /> Sealing Materia! (top 501) <br /> pth Filler Material (Below 50') <br /> P TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTAUCTfON (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial her <br /> Number of living units: Number of bedrooms r <br /> SEPTIC TANK p T -, --- `� -`-- a�iWater,�table depth •: <br /> Character of soil to a depth of 3 feet: <br /> Type/Mfg Capacity No. Comp rtmen s� �'".1 <br /> PKG. TREATMENT PLT. [_1 it # l <br /> Method of"Disposal n <br /> Distance to nearest: C, <br /> ell Foundation Property LineOF _ <br /> rv- I <br /> LEACHING LINE ❑ No. & Length df liners Total lengthrsize <br /> FILTER BED <br /> Q Distance-toy a�redsu Well Foundation `Property Line <br /> l <br /> SEEPAGE PITS ❑ Depth A Size Number <br /> a � 11 <br /> SUMPS ❑ Distanceto iTearest: Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ ' ! <br /> plication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this ap <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 perform nce o�ork-for which this permits issued, I shall not <br /> employ any person in such manner as to become subject to-workman's compensation-laws.of-Cahforniarikc"6tractor's hiring or sub- ontracting signature <br /> certifies the following: "I certify that in the performance:of the wo't'k'ftlirhich ttii§permit is issued?1 shail employ persons subject to workman's com ensa- <br /> tion laws of California." 1ti - 1 p <br /> The applicant must call for all requir d inspections. Complete drawing on reverse side. <br /> Signed Title: ! <br /> t Date: .: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ! " Date Area <br /> Pit or Grout Inspection.by i� Date ` [�� �p�� <br /> Final Inspection by - Date <br /> Additional Comment—�a. f <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 i <br /> FEE AMOUNT`DUE -AMOUNT REMITTED CK RECEIVED BY' DATE PERMIT'NO. }t <br /> INFO f <br /> + EH 13-24IREV.1/e sl V•0 <br /> EH 14-28 <br /> i <br />