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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 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/of 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. <br /> t47ss 11M-4' 2-zr,o 3 <br /> Job Addressq(JAYjL� 6 Die - �4 MAP'& `ho) City Lot Size PM <br /> Owner's Name IfC�7� el= Address f Phone 24001 <br /> Contractor • , W&- Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE '\11 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS U] <br /> ❑ Industrial - ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack E Tracy Type of Casing Specifications <br /> M Public W1 Other elta Depth of Grout Seal T pe of Grout _ <br /> 1�.5°T'>6�� , .,yyr� ,L ,t <br /> I i Irrigation ( rApprox. Depth astern Surface Seal Installed by e, J/�L fir} <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> �IIron W I aamete Sealing Material {top 50'1 r/► , "' <br /> f ' �' ept ,�r'! M� Filler Material (Below 50'1 _ 1I'[3+ It <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 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 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size _ Number <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, an <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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur <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 compens <br /> tion laws of California." <br /> The applicant must call fair all.required inspections. Complete drawing on reverse side. <br /> Signed X �, A I Title: f /�© � Date: <br /> ^EPARTMENT USE ONLY <br /> Application Accepted by _ _ _ e Date - [��s_ Area 92 " <br /> Pit or Grout Inspection by Date Final Inspection by t.e1 Date 3 p <br /> Additional Comments:� 't IY­ - A4 5 G r <br /> ❑ Stk 466-6781 Ll Lodi 369-3621 Mant ea 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95?01 <br /> a16 <br /> P4G � , t- C.rtp5-- _4 � . W4�� <br /> ri lC� I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> K9 RECEIVED BY DATE PERMiT_NO <br /> +E61 13-24(REV,$/A s1 <br />