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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 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 /> Job Address 1 5� 1 o �Q - � City Lot Size PM <br /> Owner's Nam Address( � ` va0 Phone <br /> — """Coritracldr .Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 9_4— <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welk Casing <br /> ❑ Domestic/Private LI Gravel Pack O Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> j I I Irrigation_ _..Approx. Depth• I I Eastern Surface Seal Installed by <br /> 1 Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Y� Well Destruction L] Well Diameter Sealing Material (top 50') <br /> `�\ r Depth Filler Material (Below 501 <br /> -� TYPE OF SEPTIC WORK: NEW INSTALLATION Vr REPAIR/ADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> c� ­'av`ailable within 200166 7t )— <br /> Installation <br /> " <br /> 1 I Installation will serve: Residence 1' Commercial_ Other <br /> Number of living units: __�_ Numb of bedro ms <br /> Character of soil to a depth of 3 feet: Water table depth �} <br /> SEPTIC TANK ] Type/Mfg Capacity_ No. Compartments —�. <br /> i PKG. TREATMENT PLT. ❑ l f Method of Disposal <br /> Distance to nearest: Well _VW T Foundation C> Property Line fltzo <br /> V� `LEACHING LINE ) No. & Length of lines ��y T?tal length/size <br /> %. <br /> Q\ -FILTER BED ❑ Distance to nearest: Well�'�` Foundation k5; _ Property Line <br /> mPITS :'_. Depth ___. ���{ Size I_Q- X Y ijfumber <br /> ^'L Distance to nearest: Well Foundatio Property Line <br /> �D:,ISPPEL PONDS--.,SID <br /> :l 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,Di§trict. .f <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." 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 must call for ail.required:inspecticnks. mplete drawing on reverse side. <br /> Signed X Title: � - - ,Date: <br /> `FOR_t3EPAFtTMENT,USE-ONLY _ <br /> Application Accepted by I Date Area <br /> .., it orGroutInspe tion by•: / }- 1 Date } } - j Final Inspection by ate �- <br /> Additional Comments: f ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621' 111' ❑ Manteca 823-7104 [ C]'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 <br /> t h <br /> INFO K if AMOUNT DUE AMOUNT. CASH <br /> SASH RECEIVED By DATE PERMIT-NO. <br /> ♦.EH13-24(REV. ins) <br /> i EH 14-29 / '� <br />