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APPLICATION FOR PERMIT'` 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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/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 / City Lot Size PM <br /> W <br /> Owner's Name F✓ >Y[� t�l --_ Address � �� Phone <br /> ,, 1 r �i <br /> Contractor� ���lff Address License No.: ? A0 Phone <br /> TYPE-OF WELL/PUMP: !� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> i <br /> . DISTANCE TO NEAREST:..-SEPTIC TANK SEWER LINES DISPOSAL FLO. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ECIFICATIONS <br /> ❑ Industrial r ❑ Open Bottom 0 Manteca DiExcavation Dia. of Well Casing <br /> EI Domestic/ IDGravel Pack LJTracy Type of Casing Specifications <br /> 1-1 Public ❑ Other .A-Delta Depth of Grout Seal Type of Grout <br /> 1.1 Irrigation �.Approx. Qep h I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P, t State Work Done <br /> Well Destruction 0 Welll Diameter Sealing Material (top 50') �tRl <br /> RI <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I +REPAIR/ADDITION I I DESTRUCTION INo 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 /> x- SEPTIC TANK ❑ Type/Mfg _ ___ Capacity No. Compartments- <br /> PKG, TREATMENT PLT. ❑ �II Method of Disposal <br /> :Distance to nearest: Well Foundation Property.Line <br /> Nil _ <br /> LEACHING LINE ❑. No. & Length of lines Total length/size <br /> :6. <br /> FILTER BED' ❑ Distance to nearest: Well Foundation f.Property Line <br /> I <br /> SEEPAGE PITS I 1 Depth .Size Number <br /> SUMPS ❑ „Distance to nearest:" "Well Foundation Property Line <br /> DISPOSAL PONDS ❑ II <br /> 1 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. <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 r <br /> certifies the fallowing:"I certify-that in the performance of.the work for which this permit is issued,l shall employ persons subject to workman's compensa-, <br /> tion laws of Califorhia." <br /> r The applicant t call for all required inspe tions" Complete drawing on rover i e:,--_ _ <br /> H ,g <br /> Signed X � Tide: C D•7 date: G �� <br /> F DEPARTfNENT USE ONLY <br /> Application Accepted by Date Area <br /> w II� c � <br /> Pit or Grout Inspection by Date Final Inspection by Vold Date <br /> Additional Comments: . <br /> � /I/ - <br /> C) Stk 466-6781 ❑ Lodi 369-3621 0 Manteca. 823-7104 ❑ 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 /> y <br /> FEE <br /> INFO AUNT DUE AMOUNT REMITTED CKO CASH RECEIVED By �j DATE PERMIT'NO. <br /> +. I REV.r/x 51 <br /> EH 14-2e <br />