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� t - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> 4 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w - x (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 /> 1 4: made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. , a;,.. ► A <br /> Job Address J nc' w t 7}Y� ' — City <br /> ( Lot Size PM <br /> Owner's NameI�CL�"�`C�2(' S <br /> -t Address -�� <br /> - Phone <br /> Contractor' - Q►r ) ddress License No. Phone <br /> .`•-^`- — <br /> T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES i DISPOSAL FLD. PROP. LINE <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 /> h ❑ Domestic/Private ❑ Gravel Pack._ - }❑ Tracy s"" Type of Casing g Specifications <br /> i <br /> El Public ❑ Other..-"'r ❑ Delta Depth of Grout Seal Type of Grout <br /> .:.. <br /> ❑ Irrigation ;Approx, Depth ❑ Eastern �. Surface Seal Installed by�y---� <br /> Repair Work Done ❑ Type of Pump . H,p, i <br /> State Work Done <br /> Well Destruction ❑ Well Diameter -{� Sealing Material /top 50') <br /> Depth * ' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION ❑_(No septic system permitted'if-public sewer is <br /> available within 200 feet.) <br /> t Installation will serve: Residence_ Commercial Other <br /> Number of living units:1-5—' Numb" <br /> er o bedrooms <br /> Character of soil"to a depth'of 3 fee'C' ^6$-- k" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ,,- s <br /> Ty <br /> p 9 1- <br /> �^ _ Capacity° ��" No.'Gompartments - - <br /> PKG. TREATMENT PLT. ❑ - r{ ' Method of Disposal <br /> Distance to nearest: Well a/ 6 Foundation ? e I <br /> Property Line I <br /> LEACHING LIN & Length of lines Totalehgth/size <br /> FILTER BEDS s 171 Distance to nearest: Well / Foundation Pro ert L� <br /> p y Line b <br /> SEEPAGE PITS '0 Depth Size _ M <br /> _ x Number <br /> SUMPS ❑ Distance to near—,,t- {Neil �� F undo lot n,�_ f`:"_Prdperty Line <br /> DISPOSAL PONDS ❑ f <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 ofthe San Joaquin1ocal Health District.". i <br /> Home owner o;.licensed agent's signature.certifies the following: "I certify <br /> that in'the, 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 /> The applicant ust calhfor_all requ' ins ctions. omplste drawing on reverse <br /> Signed s c <br /> rtle: Date: <br /> f FOR DEPARTMENT USE ONLY F` <br /> Application Accepted by i , sj %] <br /> - Date�W�" Area <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 8354MS - <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 CAR ' RECEIVED-13Y DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24{REV. - <br /> EH 14-28 <br />