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APPLICATION FOR PERMIT, <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I� 1601 E. •HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> Il 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 <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 /> i/ <br /> (� <br /> Ir e I <br /> Job Address P T- <br /> City D l 44!, Lot Size PM. <br /> Owner's Name tk VC-C yN A4r a ~Address (C1 s Q�/v /_ _-- Phone <br /> ai <br /> Contractor's Name -" .�AdCucense No. . ,� Phone 'ILI <br /> �,. <br /> TYPE OF WELL/PUMP:/UD/VC NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> C—Ir Lv.4*re PUMP INSTALLATION ❑ SYSTEM REPAIR I]- 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 ❑ Or Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> {Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. <br /> Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type'of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer isr. ~ <br /> available within 200 feet.) s <br /> Installation will serve: R.�eessidence� Commercial— Other s <br /> Number of living units: Number of bedrooms 01 <br /> Character of soil to a depth of"3 feet: Water table depth 70 <br /> SEPTIC TANK ❑ T}6/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1?"D4pth I Size IT Number j <br /> SUMPS ❑ Distance to nearest: Well A/4t Foundation IS, _ Property Line <br /> DISPOSAL PONDS ❑ Ii <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 Sen'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 subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I cerfify 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." !! s + <br /> The applicant mus call for all required inspections. C mplete drawing on reverse side. �l <br /> Signed Title: Daie: 3'2 l <br /> !i FOR DEPARTMENT.USE LY + <br /> Application Accepted by CDate Area <br /> Pit or Grout Inspection by 'Date Final Inspection by pate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi `-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 - _ ► <br /> Applicant- Return all copies to: Envirorimental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE/NFO AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT`NO. <br /> s. �a <br /> + EH 13-241REV.10/831 ~` f�M <br /> EH 14-26 44 f�Y <br />