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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> i 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 <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San <br /> permit to construct and/or install the work herein described. This application is <br /> Local Health District. - <br /> ' Joaquin <br /> Job Address <br /> LS <br /> Loi SC'�2-Q.Ql <br /> Owner's Name y PM <br /> Address /� - <br /> - <br /> Contract Q Phone <br /> _ <br /> Address '+l 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No. ?-g phone = �� <br /> > PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ pESTR!lC710N ❑ <br /> DISTANCE TO NEAREST: SEPTIC,TANK- SYSTEM REPAIR ❑ OTHER p `V <br /> -�_ SEWER LINES �L DISPOSAL FLD. f` <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS W - -- <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT_10_ N5 Q <br /> ❑ Industrial F❑ Open Bottom -�� R - - - <br /> ❑ <br /> Domestic/Private ❑ Manteca* Dia. of Well Excavation <br /> --B-Public— ,� ❑ Gravel Pack ❑ Tracy a Type,of Casing., i Dia. of Wel!Casing <br /> -�❑ Other, p pelta• -." pepth of Grout Seal Specifications <br /> ❑ Irrigation - Type-f-Grout--•- <br /> �Approx.:Depth�❑ Eastern surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump �� <br /> Well Destruction ❑ H.P. State Work Done_ 1 <br /> Well Diameter `Seaiing.Material-(top 501 <br /> Depth Filler,Material (Below 50.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Z!REPAIR%ADDITION-❑_ pESTRUCTlON ❑ fNo Septic system <br /> Installation will serve: Residence v p permitted if public sewer is <br /> Commercial' r--" - - "' available within 200 feet.) <br /> Number of living units: r�Cher <br /> Number of be rooms t"­J " ;'• i2` , <br /> Character of soil to a depth of 3 feet: * <br /> SEPTIC TANK Type/Mfg I t-. _" - Water table depth <br /> PKG. TREATMENT PLT. ❑ 1 Capacity-Z6aQ No. Compartments <br /> Distance to nearest: Well ndation <br /> LEACHING LINE <br /> i 0' T Method of Disposal <br /> .Fou �: <br /> f ��, rope+tv,Line 4 r <br /> ANO. & Length of lines Q i <br /> FILTER BED ❑ Distance to nearest: Well- � Foundation-- length/size Q X• <br /> " f i I <br /> 'total-�� Property Line <br /> SEEPAGE PITS Ll Depth SUMPS Size !f iNumber <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ u 4,�„ yFoundation Property Line <br /> 1 hereby certify that l 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: <br /> employ any person n such manner n to become subject ll workman's W that in the performance of the work for which this <br /> certifies the following compensation per laws ss California."Contractor's hiring orpesub contract ngrmit is issued, lsignalture <br />. g:"I certify that in the performance of the work for which this permit is issued shall employ persons subject to workman's com <br /> tion laws of California." <br /> The applicant st call for al aqui d inspections. Complete drawing on rev side. pensa <br /> t <br /> Signed �3 <br /> Title: t} �Z <br /> Date:(�{ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Inspection bDate Area <br /> y `'�'----� . <br /> Date Final Inspection by GZ <br /> Additional Comments: Date Z ST <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 -€ ❑ Manteca 823-7104 ❑ Tracy 835.4385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, y <br /> Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK RECEIVED BY DATE <br /> CASH PERMI7`'NO. <br /> + EH 13.24{flEV.t/657 - <br /> EN 1428 . �a <br />