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APPLICATION FOR PERMIT <br /> SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ` Telephone (200) 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 /> F ­.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.M s <br /> Y I- , 1 <br /> Job Address 1/`�.. ��'�� �ls( _ City, ^+ Lot Size PM <br /> Owner's Name _fS T Address QUw-ee Phone t� <br /> Contractor _er Address License No.-bs�)_Phone S <br /> TYPE OF WELL/PUMP: i[NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C/\ <br /> DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ^�- '-- --�—INTENDED°USE-'-"'^"""TYPE`OF WELL PR `� AI;i,CONSTRUCTION--§VECIFICdTIONS' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca - Dra. II Excavation" Dia. of Well Casing r <br /> ❑ Domestic/Private F-1 Gravel Pack 17 Tracy -Type of Casing Specifications ' <br /> ❑ Public C] Other ❑ Delta Zy; TDepth of Grout Seal Type of Grout <br /> I .M ❑ Irrigation --Approx. Depth ❑ Eastern f ­S,prface Seal installed by. <br /> Repair Work Done ❑ Type of Pump F:f'r State Work"Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 11 DESTRUCTION ❑ tNo.-septic system permitted if public sewer is <br /> ` as available within 200 feet.) ` <br /> Installation will serve: Residence Y Commercial_ Other " 6 <br /> � Number of living units: I Numbera bedrooms + ' <br /> Character of soil to a depth of 3 feed"""' ' a. L 0oyn ter table depth Y <br /> SEPTIC TANK T e/Mfg "z — r <br /> yp g- _ apacity n N No. Compartments <br /> t 'PKG. TREATMENT PLT. ❑ r Method of DiElsal' <br /> Distance to nearest: S Well Foundation :-Property un,a <br /> LEACHING LINE No. & Length of lines �_-_ � Total length/size £ <br /> FILTER BED ❑ 'Distance to-nearest:­Wellr(�n' __ Foundation # Property-tine_'_' <br /> SEEPAGE PITS �❑/Depth I Size k r a' Number 1a f <br /> SUMPS 7Q Dotance-to•nearest:"�---Well .._ _—Foundation Property Line � A <br /> DISPOSAL PONDS ❑ 1 tl <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. t" ` <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•cornj ensetion 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 /> r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X 1AA Title: _ G1pY1:r Date: <br /> FOR DEPARTMENT U E ONLY <br /> Application Accepted by I Date Area I <br /> Pit or Grout Inspection by Date Final Inspection by Date 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369;3621 ❑ Manteca 823-7104 ❑ Tracy 8351-6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE s� I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> ASH RECEIVED BY DATE PERMIT NO. <br /> I +EEH 13-24 H 1428(REV.1/e 51 <br /> dZ {i <br />