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APPLICATION,FOR PERMIT <br /> SAN JOAQUINLOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,ISTOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (complete in Triplicate),, f <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. <br /> ,.. r•,.. a ,^r; . -. „ _� :�. jai <br /> Job Address City" Lot Size PM <br /> Owner's Name Address —tra I �1�d ���'7 Phone W <br /> Contractor a ddress Ca License No. " Phone_ <br /> TYPE OF WELL/.PUMP: ,—NEW WELL E1 WELL REPLACEMENT F-1DESTRUCTION [IPUMP INS_TgLLATION ❑ SYST REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES" DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE AREA ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation Dia. of Well Casing <br /> ❑ Domestic/Private, ❑ Gravel Pack ❑ Tra gi —TypeCasing-- <br /> _ " - <br /> 33 y ype of Casing �- Specifications <br /> C1 Public ❑ Other t ❑ Delta" " — Depth of-Gfout Seal " -Type of Grout <br /> ❑ Irrigation —I—Approx. Depth ❑ Eastern ace.Seal Installed by <br /> Repair Work Done ❑ Type of Pump } H. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501_ t <br /> Depth 1 v <br /> p Filler Material IBelow 501 b <br />`w TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAiR/ADDITION ❑ ;,DESTRUCTIO o septic system permitted if public sewer is <br /> "a ilable within 200 feet.) 1 <br /> Installation will serve: Residence Commercials Other <br /> T_ E. r { <br /> Number of living units: Number of bedrooms I I a <br /> Character of soil to a depth of.,3 feet: f Water table depth <br /> SEPTIC TANK ❑ i T ` i <br /> i ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' Lo <br /> Method of Disposal " <br /> Distance to nearest: Well —Foundation ---_ .Property-Line <br /> �f? 41 <br /> LEACHING LINE ❑ No. & Length of lines I. Total length/size I 4 <br /> FILTER BED ❑ Distance to nearest: Well Foundation s `Property Line <br /> .- <br /> SEEPAGE PITS [--]I Depth t Size x t! t Number F <br /> SUMPS ❑y Distance to nearest: Well Foundation L Property Line <br /> DISPOSAL PONDS ❑E <br /> 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 a erlt's signature certifies the following:9 g g: "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 mus call for all req u'ed inspe ions. Complge drawing on Date: <br /> re a side. <br /> Signed Title: a� <br /> - <br /> j FOR DEPARTMENT USE ONLY <br /> Application Accepted byyw Date � Area <br /> y— <br /> Pit or Grout Inspection Date f Final Inspection by > Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 �Ci 369-3621 �nMnte. 823-7104 - ❑ Tracy 835 63$5 1 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009, Stk., CA 95201 [ <br /> INFO MOUNTD�UE <br /> —T—AMOUNT REMITTED K H RECEIVED BY DATE PERMIT N0. <br /> FEE. EH 13-24 IflEV. <br /> EH 1428iiH51 ��� �._ �✓�_ `� V <br />