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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (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 s <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. n 3 Ole�� <br /> Job Address __ i /"T 6 H City m A tJiM Lot Size ZOD'XI00 , PM <br /> Owner's Name W,/)t qM L 1)/J&— Address t Q 3 Phone i - <br /> S257/5-Contractor's Name License No. Phone 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> + PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other V <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK A<Type/Mfg pew L _ Capacity /Zo o No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disgosal S 4 <br /> Distance to nearest: Well 70o / Foundation ' Property Line x <br /> d <br /> • Ile \k <br /> LEACHING LINE ?51No. & Length of lines 7 Total length/size ' {may\11 <br /> FILTER BED ❑ Distance to nearest: Well?G U Foundation /D //4- Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 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:Fut <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 must call for all req iced i pections. Complete drawing on reverse side. <br /> Signed � Title: 4. Date: r _ <br /> FOR DEPARTMENT USE ONLY �^ <br /> Application Accepted by Date l' 4J Area <br /> `` k` <br /> Pit or Grout Inspection by fV A Date - Final Inspection byData <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 ❑ Lodi 319-3621 >rManteca 823-7104 ❑ Tracy 835-6.385 <br /> Applicant- Return all copies to: Environmental Aealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY t DATE PERMIT NO. <br /> + EH 13-24[REV.10/83! �y , 0O /y R,u <br /> EH 10.28 � 1( S <br />