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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i 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 <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. p?l�� 9 , D <br /> L <br /> ' y <br /> — City Lot Size PM <br /> .lob AddressTK d <br /> Address _ 9/1' Q s Phone $J Pd�Z <br /> Owner's Name / <br /> f �c✓� License No b/f Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK W" SEWER LINES DISPOSAL FLD. PROP. LINE PRJF_10 <br /> FOUNDATION CO°_.— AGRICULTURE WELL —Ale OTHER WELL PITS/SUMPS /I& <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> VeDomestic/Private Gravel PackL1Tracy r Type of,Casing /� - Specifications /61' <br /> M Public f! Other t F1 De Depth of Grout Seal Type of Grout <br /> 9q E <br /> I I Irrigation p2WO(Approx. Depth I I Eastern Surface Seal Installed by Ohm - <br /> Repair Work Done ❑ Type of Pump W.P. ,) State Work Done <br /> Wel! Destruction ❑ Well Diameter Sealing Material [top 50'1 , - <br /> s 4 } <br /> Depth `Filler Material (Balow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 lNo septic system permitted if public sewer.is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial .Other`s <br /> Number of living units: Number of bedrooms 4! (� <br /> Character of soil to a depth of 3 feat: Water table depth r <br /> SEPTIC TANK 13 Type/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 Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> .. r <br /> SEEPAGE PITS I 1 Depth Size Number j <br /> SUMPS ❑ Distance to nearest: Well 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 must call for a required inspections. ComjIete drawing on reverse side. <br /> Signed X Title: Date: / <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Daten7-/­_t?— Final 1 pection by <br /> Additional Comments: 0-41( /14 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Ma eca 823-7104 ❑ Tracy 83 -6385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO +� l <br /> +.EH}3-24(REV.t i K 51 ,Q,� ti 1�`. �1��/ 71�!21 <br /> EH 1428 <br />