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i APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAS _ <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 <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 /> Lgcal Health District. <br /> � y _.y - <br /> Job AddresW��SLJ �• ��r�Y�"'; ^ ' _ t <br /> / C <br /> i <br /> ty 63C d Lot Size PM <br /> Owner's Name eiv, d _Z Address <br /> Phone <br /> o n t r a c t o r �/Gr �00�' 4 � Z Address <br /> License No. Phone D <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial , 0'Open Bottom" ❑ Manteca' -- -Dia.-of Well Excavation <br /> EJDomestic/Private ❑ Gravel Pack EJ Tracy Type of Dia. of Well Casing <br /> Casing Specifications �t <br /> EJ Public f ❑ Other El Delta Depth of Grout Seal t� <br /> El Irrigation .—Approx. Depth EJ Eastern Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done .,❑ Type of Pump H.P. State Work Done a91— <br /> Well-Destruction Destruction" ❑ -i Well Diameter *^� — <br /> i, . Sealing Material (top 50') <br /> ' 0 :Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will'serve: Residence— Commercial_ Other <br /> l f <br /> Number of.living units: Number of bedrooms <br /> Character of soil to a pth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ; Type/Mfg 43S-::���Cpacity�PKG. TREATMENT PLT. C1 No. Compartmerits <br /> Method of Disposal <br /> y i Distance to nearest: Welt Foundation Property Line r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size a y <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> s V' <br /> SEEPAGE PITS ❑ Depth Size Number " <br /> SUMPS ❑ Distance to nearest: Well " <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call fo all required ' pections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> 1�n FOR DEPARTMENT USE ONLY <br /> Application-Accepted by Date <br /> Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> - - Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 3621 ❑ anteca 7104 Cl Tracy 835 6385 / C <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED .r <br /> c, INFO [—+ -CK H jCEIVED BY p`A}TE�/`� P�EJRMI,T�NO. <br /> + EH 13-24 EH 14-26 1REV.1/e 5) �3, /�� � 4� %J / �rl�Q <br /> �-'C� i - s <br />