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l <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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/or install the work herein described. This <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and the Rules and Regulations of the S j <br /> Local Health District. <br /> i s application is <br /> San Joaquin <br /> Job Address � � e i <br /> � City Lot Size <br /> Owner's Name ` PM <br /> Address <br /> t6 Z 2 <br /> Contractor <br /> Phone <br /> Address <br /> TYPE OF WELL/PUMP: �� �v <br /> SEW WELL ElLicense N Phone �d <br /> PUMP INSTALLATION ❑ LL REPLACEMENT EJDESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSYSTEM REPAIR 1iOTHER CJ SEWER LINES DISPDSAL FLD. <br /> FOUNDATION.— AGRICULTURE WELL PROP. LINE <br /> INTENDED USE TYPE OF WELL PROBLEM AOTHER WELL S/SUMPS <br /> AREA CONSTRUCTION SPECIFI <br /> 11 Industrial O Open Bottom a S <br /> 11 Domestic/Private CONSTRUCTION <br /> Dia. of Well <br /> ❑ Gravel Packon Dia. of Well Casing <br /> M Public Cl❑ Tracy a Casing <br /> (_1 Other # b - Specifications <br /> i I irrigation �'� Depth of GroinSeal— """"""'­ <br /> --Approx. Depth I I Eastern Surface Seal Installed by Type of Grout <br /> Ffepair Work Done. ❑ T --�— <br /> Type of Pump4 H,P. <br /> Well Destruction ❑ Well Diameter! State Work Done{ <br /> , <br /> ~ <br /> Depth Sealing Material (top 50') <br /> p Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK; ;NEW IfVSTALLATION I I REPAIR/ADDITION {J DESTRUCTION a <br /> (No septic system permitted if <br /> Commercial Other public sewer is <br /> _ Installation will serve: Residence available within 200 feet.)N -- <br /> umber of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTlC TANK /,El 'Type/Mfg I '. Water table depth <br /> PKG. TREATMENT P.LT.' f Capacity. No. Compartments <br /> Method of Disposal <br /> Distance to nearest: f Wey Foundation- r <br /> 'r I —�� _Property'Linye <br /> LEACHING LINE ❑ No. & Length bf lines U L I c <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> { Foundation_ Property Line <br /> SEEPAGE PITS f I DepthS <br /> I <br /> ize Number <br /> SUMPS ` Y <br /> L7 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby certify that I have prepared this application and that the work will be on in accordance with San Joquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. a <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." Contractors 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 st call for all required inspections:Complete drawing on reverse side, <br /> Signed X + ` <br /> w "Title: g91_ <br /> �..1�;;..b���.� Date: <br /> FbR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date 'ti <br /> Pit or Grout Inspection by Area <br /> Date Final Inspection by <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 <br /> Tracy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E,❑Hazelton 3Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT'DUE i AMOUNT REMITTED F CK <br /> CASH RECEIVED BY DATE PERMIT NO. ) <br /> + EH 13-26(REV.tigs1 <br /> EH 14-28 (fir ��� <br />