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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t/s- F41 <br /> f.` > 1601_' AHAZELTON AVE., STOCKTON, CA { <br /> Telephone (209) 466-6781 ` <br />�i PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . rf^ Application is he+eby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> V 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 /> s Locai Health District. `. <br /> TB <br /> d.►c City t Size <br /> PM <br /> Job'-Address ' � dr, Y�-7 <br /> C <br /> 731 �5 <br /> dr ss Phone <br /> Owner s Name (\ <br /> Contractor Address License W. Phone_ i <br /> TYPE OF WELL/PUMP: 1 N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATIONO^ _ _ SYSTEM REPAIR ❑ OTHER 171 <br /> DISTANCE TO NEAREST: SEPTIC TANK T 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 171 Open Bottom L7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> FI Public 4 0 Other n Delta Depth of Grout Seal Type of Grout — <br /> I I Irrigation _._Approx. De �I I Easta� 2 Surface Seal Installed by <br /> Repair Work Done C7 Type of Pu r H.p. State ork Done <br /> Well Destruction ' I" Well Diameter q 0Se®aJli/ng Material (sap-5fjri <br /> ( �+ Depth fi Material (Bal ftr ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI 11 REPAIR/ADDITION I.I DESTRUCTION I i {No septic system permitted if public sewer is <br /> tE available within 200 feet.) <br /> I(A <br /> Installation will serve:_Residence_ Commercial_ Other <br /> Number`,of living units:` Number of bedrooms <br /> Character of s6il to a,depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ! ~`i0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT=PLT?❑ Method of Disposal <br /> �. Distance to nearest: Weil Foundation Property Line <br /> 4 JP <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE4PITS I i Depth Size Number <br /> SUMPS j 0 Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS L1 <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 i nsed 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 person in uch ma nor a become subject to workman's compensation laws'of California." Contractor's hiring or sub-contracting signature <br /> certifie tfia foliowin "I certi a n e performance of the work for which this permit is issued, I shall.employ persons subject to workman's compensa <br /> tion la s of Cal'o i <br /> The a licant st all f r c ' ns. Complete drawing on a sid <br />' r Title: Date: /Z f <br />' Signed <br /> FQR DEPARTMENT USE ONLY p <br /> Application Accepted by 222L <br /> v Date D Area <br /> l <br /> 1 Pit or Grout Inspection by Data Final Inspection by Date ! d <br /> Addl tonal Comments: <br /> ❑ Stk 466-6781 D Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant t- 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 CASH RECEIVED BY DATE PERMIT NO. - <br /> INFO <br /> + EH 13-24(REV.t/n 5] 4,3S— -- <br /> EH 14-28 <br />