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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209)_466-6781 <br /> PERMIT EXPIRES TYEAR 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 Joe in 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 /> 233OX��Z(7 PM <br /> Job Address City' Lot Size <br /> '+ <br /> Owner's Name Add essPhone�. - _ � � � <br /> 9�7 <br /> Contract --- .Addres's '_"" '"'"'""�"""" °'-L`icense•"Noo Phone - <br /> yr <br /> .- - r � <br /> TYPE OF. L/PUMP: WW WELLElWELL REPLACEMENT Cl DESTRUCTION ❑ <br /> r <br /> .PUMP INSTALLATION ❑ SYSTEM REPAIR F-1OTHER ❑ <br /> t .. .c. <br /> DISTANCE:TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL fLb. PROP. LINE } <br /> " FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS "` a t <br /> INTENDED USE f 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial 1 ❑ Open Bottom El Manteca Dia. of Well"Excavation Dia. of Well Casirig <br /> f <br /> ❑ Domestic/Private ❑'Grraavel Pack" ' ,, ElTracy Type of Casing Specifications .._ <br /> F1 Public Cl Other; El'Deltl- Depth Sot Grout Seal r Type of Grout <br /> ! I Irrigaiio ..Approx. Depth I i Eastern Surface`Seal,'Installed by - <br /> f <br /> Repair-Woik-Done ❑ Type of Pump H.P. State Work Done_ <br /> ,. r <br /> Well Destruction s P..,,,Well Diameter SealOg 1Material (top 501 _ <br /> 1�.Depth r ; Filler Material 18elow 50�) " <br /> ':TYPE OF SEPTIC WORK: NEW INSTALLATION Isl--REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is <br /> _,. o� available within 200 feet.) <br /> Installation will serve: ResidenceCammereial Other p y . <br /> -t, 7 r c ii a E <br /> Number of living units: Number-of bedrooms; <br /> E Character of soil to a depth of 3,,feet: y k y �y Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity' Compartments 1 <br /> No. <br /> PKG. TREATMENT PLT. L] ' �` w Method of Dis osal <br /> ! Distance to nearest: Well Foundation ` t Property Line Z.__ , <br /> 3 r + } � <br /> LEACHING"LINE No. & Length of lines "Fotal length/size � <br /> i FILTER BED LJ Distance to nearest: Well Foundation.�� Property Line f. <br />' SEEPAGE PITS l'I Depth Size .,__ Numt;ef"tom <br /> SUMPS L1 Distance to nearest: Well i n Foundation Property Line <br /> I 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."Contractors 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 applicamust call for required i spections. Complete drawing`oh reverse side <br /> X <br /> Title: Date: <br /> Signed <br /> 4 f <br /> FOR DEPARTMENT USE ONLY 1 <br /> • r1 t-�3 �t �s t7ta � r <br /> Application Accepted by Date '`7Area <br /> Final Inspection by Date <br /> Pito Grout Inspection by ate <br /> F✓ J�'f�)s�i _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi' 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> i )NFO <br /> + EH 13-24{REV.1 H 51 ��� t,' �' _ijl�� [�.! . U�-.y.,J i <br /> EH 14-26 <br /> r <br />