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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ll <br /> ` Telephone (2093 Y v� U <br /> fi <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San l oaquin 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 /> Job Address ' I �' t"y,�y City / " ' � Lot Size PM <br /> i Owner's Name I " '��e r -�o Address I"�l� �!' �JW < �U �'V.�3 <br /> -r 1.-.z� Phone <br /> a Contractor Address License No. Phone <br /> F E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER D <br /> k DISTANCE T : SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINF <br /> FOU AGRICULTURE WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL STRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom anteca Dia. II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ack ❑ Tracy Type of Casing Specifications <br /> FI Public ❑ Other f l Delta Depth of Grout Seal Type of Grout <br /> j I I Irrigat' �..Approx. Depth I I Eastern Surface Seal Installed by <br /> f€ Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> i Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOREPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> Z <br /> available within 200 feet.) <br /> tInstallation will serve. ResidenceCommercial Other <br /> Number of living units: � Number of b/eed-�ro s �A. �a: <br /> r Character of soil to a depth of 3 feet- Water table depth a � <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ �nn 0, Method of Disp I <br /> �� <br /> Distance to nearest: Well� Foundation Property Line <br /> LEACHING LINE No. & Length of lines �O To Ja <br /> I length/size <br /> FILTER BED ❑ Distance to nearest: Well�e/� -- Foundation Property Line , <br /> I <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Prop"-Line <br /> DISPOSAL PONDS ❑ I <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 of the San Joaquin Local Health Di1trict. <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.f6r whichithis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." / \ <br /> The applicant must call foil required inspections. Complete drawing on reverse\side. <br /> Signed X Title: _1A Nr_4A -- -f -� Date: ' 1 <br /> F PARTMENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> i <br /> Additional Comments: <br /> D Stk 466-6781 D Lodi 369-3621 D Manteca 623-7104 ❑ 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 INF% MOUNT DUE AMOUNT REMITTED CCK 9 RECEIVED BY DATE <br /> EK 4-26 PERMI7'Np, <br /> t ♦.EH 1 -241REV.r/n5) <br /> r` <br />