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Application is hereby m+ <br />made in compliance witl <br />Local Health DIS�io Y <br />Job Address <br />T Owner's Name <br />Contractor's Name <br />APPLICATION TOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON .AVE., STOCKTON, CA <br />Telephone (209) 466-6781 9 e <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5 - <br />,:.:.::ititrJ",•.(Complete.in Triplicate),, 1i <br />i to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br />an Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations oftheS n s q r <br />Gi4�11� Lot SzeA <br />_• <br />Address <br />-� .. License No. <br />Phone w`r <br />Phone <br />TYPE OF WELL/PUMP.: <br />NEIN.WELL! IA.— .. --WELL REPLACEMENT ❑ ots i KVL i WN u <br />" <br />PUMP INSTALLATION r_1 REPAIR L3 OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK <br />SEWER LINES DISPOSAL FLD. <br />EWER <br />PROP. LINE <br />FOUNDATION <br />AGRICULTURE WELL OTHER WELL <br />PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />. <br />L1 Industrial. <br />❑ Open Bottom <br />El Manteca Dia. of Well Excavation <br />Dia. f WCasing _ <br />[D Domestic/ Private <br />❑ Gravel Pack <br />Q Tracy Type of Casing - <br />Specifications <br />7 Public <br />❑ Other <br />❑ Delta Depth of Grout Seal <br />Type of Grout <br />-1 <br />❑ Irrigation <br />­Approx. Depth <br />❑ Eastern Surface Seal Installed by <br />Repair Work Done ❑ ' <br />Type of Pump <br />H. P. State Work Done <br />Well Destruction ❑ Well Diameter <br />Depth <br />TYPE OF SEPTIC WORK: NEW INST <br />easing Material (top 501 — <br />Filter Material (Below 50'1 — <br />REPAIR/ADDITION ❑ DESTRU, <br />c -J t t - <br />(No septic system permitted if public 'sewer is <br />available within 200 feet./ ' rte, V <br />Installation will serve: R iden e V Commercial Other <br />Number of living units: Number of bedrooms k �! ",,�•�*"^ <br />Character of soil to a dap of 3 feet: Water table depth <br />SEPTIC TANK Typa/Mfg 4- 4 Capacity No. Compartments <br />i Method dposal <br />.- <br />PKG. TREATMENT PLT. ❑ - { t ro <br />'Distance to nearest:' Well 3_ Foundation— Property Line - <br />' �• Total length/size 1 <br />LEACHING LINE "�� No. &Length of lines <br />! -�- FIL-TER BED ❑"'Distance to nearest: Well - Foundation Property Line <br />q \ <br />SEEPAGE PITS ❑—Dept#h " Size Number <br />-SUMPS•"'- _ ❑""Distance to nearest: ;Well " ' Foundation' Property Line <br />DISPOSAL PONDS/\ ❑ r: .:.T; ! <br />ereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br />rule and regulations of the San'Jo`aquiri'Local Health District. <br />Homed ner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, I shall not <br />employ a rson in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub -contracting signature <br />certifies t - Ilowing: "I rti that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br />tion la f alifo y'Ia."{( ry <br />The apple n 1l or. al f i d ' s tions. Complete drawing on reverse sidq�J , <br />� V- ��j 1�,\ " <br />Signed f d Title:.. Date <br />FOR DEPARTMENT USE ONLY <br />7 <br />Application Accepted by Date Area <br />Pit or Grout Inspection by Dat nal Inspection by Date <br />Additional Comments: 4 <br />❑ Stk 466-6781 - ❑ Lodi 369-3511 ❑ 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 />r INFO <br />+ EH 132$ ff1Ey..70/681 -...�--sY <br />'� EH.1428 <br />DUE I AMOUNT -REMITTED <br />RECEIVED BY DATE <br />