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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI.TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - ., x� t <br /> [Complete in Triplicate) , <br /> �. e a = <br /> scribed. This application is <br /> Applicaticompliance with San Joaquin County <br /> is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work here deY• ul <br /> Ordinance No.549 for sewage or No. 1862 for well/pump and the Rylee s and Regulations of the San Joaquin <br /> made in <br /> Local Health District. <br /> Lot Size f , ►� PM <br /> Job Address <br /> Pi-W <br /> Y City ' <br /> i I: s a <br /> Phone <br /> Owner's Name <br /> [: D,f r Addres& is-z <br /> ta.Ds Addressed. N�CEMEN�; O <br /> LcenseNf tiPhone <br /> Contractor DESTRUCTION ❑ <br /> TYPEOFWELL/PUMP: NEW WELL ❑ WELL <br /> PUMP INSTALLATION ®' <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> i SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK MPS E\ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SU_ <br /> INTENDED USE. TYPE OF WELL- - PROBLEM AREA CONSTRUCTION SPE I & T Dia. of Well Casing <br /> j <br /> C,Industrial Ll open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Domestic/Private ❑ Gravel Pack C] Tracy Type of Casing <br /> k ❑ Public <br /> El Other ❑ Delta Depth oft Grout Seal Type of Grout <br /> ` ❑ Irrigation �ppr_ox. Dept ❑ St <br /> Eas_tem- .� Surface Seal Installed by <br /> =-� P--�` ate Woik Done <br /> Repair Wor <br /> i k D`dne t�.—Tgrpe'o1'Pump <br /> tt <br /> i F7, Well Destruction E3Well Diameter Sealing Material flop 50'1 <br /> :. Depth Filler Material (Below 501 <br /> o <br /> erm <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 11 `DESTRUCTION ❑ alvailabpelwit in 20sysm0 feet,) <br /> itted if public sewers <br /> l Installation will serve: Residence Commercial Other - <br /> jr• �i,� <br /> -�- Number of living units: --xNumber.of-bedrooms"-� s" "`r" " Water table depth <br /> - Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg .� f 4, Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I <br /> r Distance to nearest: Well Foundation Property Line <br /> } <br /> Total length/size <br /> LEACHING LINE (D No. & Length of lines <br /> 1 <br /> `' w�! Foundation Property Line <br /> FILTER BED E3 Distance to nearestr Well r c <br /> SEEPAGE PITS ❑- Depth <br /> SizeNumber <br /> El Distance to nearest: Well. TLrI Foundatio <br /> SUMPS n ' Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application-and-that the work will be;do-ne in accordance-with San Joaquin-county ordinances; state laws, arid <br /> x rules and regulations of the San Joaquin Local Health District. 1 <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, l shah 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'permiit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> E The applicant u t for•all u' inspections. ompleteyydr��a Ang on revers s e. / d—3— <br /> "l 'tie: Date: <br /> Signed I <br /> FOR DEPARTMENT USE ONLY /� <br /> s <br /> Date 1 U f Area <br /> Application Accepted by v i may,_ ll 9 7 <br /> r. Final Inspection by !�/ Date <br /> Pit or Grout.Inspection Date <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385, P. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009.Stk., CA 95201 <br /> ' CK RECEIVED BY DATE PERMIT <br /> FEE AMOUEEIOUNT REMITTED CASHINFO+ EH t3-24 iREV.)EH W26 - - <br /> _ <br />