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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALT_.,DISTRICT I <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 (7 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete inTriplicate) <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. co <br /> s <br /> Job Address Z�- - �, �� City a Lot Size PM <br /> y�c� <br /> Owner's Name ,t' ``_�` Address LE Phone <br /> Contractor 'Address License No. r Phone_ 1 <br /> TYPE OF WELL/PUMP: ,NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 4; PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ J <br /> DISTANCE TO NEAREST:-SEPTIC TANK � S ER, LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AG ULTURE WELL OTHER WELL' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROABe <br /> ON UC710N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca ' of Well Excavation Dia. of Well Casing <br /> ' Domestic/Private © Gravel Pack ❑ Type of Casing Specifications <br /> Ll Public - [ 1 Other {l th of Grout Seal Type of GroutI I Irrigation � --Approx. Depth I Eu ce Seal Installed byRepair Work Done ❑ Type of Pump - State Work DoneWell Destruction ❑•"'`Well Diameter terial It 50')Depth ial IBelo ) s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public'sewer is t <br /> available within-200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> ` Number of'living units: �_ Number of bedrooms <br /> Character of soil to.a'depth of 3 feet: Water table depth <br /> � 1 <br /> k. <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Co'mpa`rtments '^,PKG. TREATMENT PLT. ❑ t Method bf Disposal <br /> ° '-Distance to nearest: Well Fdation�_ Property line i <br /> 4` LEACHING LINE Lam- No: & Length of lines + Total le'gth/size <br /> r w <br /> FILTER BED l6 Distance to nearest: Well Foundation i(5 Property Line• 1 i <br /> v <br /> SEEPAGE,PITS L)- Depth �. -Size /.7 _ Number f <br /> SUMPS Ll Distance to nearest: Well Foundation - Property Line r <br /> DISPOSAL PONDS ❑ j hti <br /> 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 subjectto w'arkman's compensation laws of California." Contractor's hiring or sub-contracting signature i <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 mut call for all required inspections. Complete drawing on reverse side. <br /> Signed X " 4 Q� ` Title: Date: _ <br /> F DEPARTMENT USE ONLY Y -ry��, <br /> Application Accepted by &:-RIA_, Date - `� "'� AArra�� 12 <br /> } <br /> N Pit or Grout Inspection by Data 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., CAFEE 9� <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK <br /> RECEIVED BY DATE PERMIT"NO. <br /> 3 � �/.L} 2 /Yet <br /> +.E1113241REV.i/N51 70--62 !De m,f r r J tO Yet <br /> f L/ <br /> -4 EH 1 -26 <br />