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k <br /> APPLICATION FOR PERMIT • <br /> k <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> * .F <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> k 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. ., 4 I <br /> a <br /> Job Address JJ. r/l- a ' <br /> City rrl4;Lot Size Z049 PM <br /> Owner's Name �, .Y <br /> G� Idress Phone -5 o� <br /> Contractor. a Address <br /> TYPE OF WELL/P MP: License No. 7 Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE:OF WELL t PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial QxOpen Bottom i Q Manteca Dia. of Well E icavation.ft•A <br /> ❑ Domestic/Private ❑ Gravel Pack . o Well Casing - <br /> ❑ Tracy Type of Ca <br /> Specifications 11 <br /> LJ Public ❑ Other E ❑ Del epth of Grout Seal r -� 1 <br /> ❑ Irrigation --Approx. i Type of Grout <br /> Eastern Surface Seal;Installed by <br /> Repair Work Do a of Pump H.P. ' <br /> .� t State Work Dane <br /> Wel! ruction ❑ WieIILDiameter Sealing Material(top'S0') <br /> Depth 'A�� h*i -:� <br /> FiRer,TGMaterial {Below 50') <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION•p REPAIR/ADDITION ❑ pESTRUCTION INo septic system permitted if Lpublricsewer is <br /> available within 200 feet.l �1 <br /> Installation will serve: Residence J Co, 1"'!-'W p her v <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: --^�--- ---� <br /> SEPTIC TANK Water table depth <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ l ; <br /> q Method of Disposal <br /> Distance to nearest: Well Foundation <br /> k R< < I Property Line <br /> f _ k <br /> LEACHING LINE ❑ No. & Length o6lines' } ; <br /> r Total length/size <br /> FILTER BED Distance tofnea Fest: Well Foundation Property I rty Line� p e <br /> SEEPAGE PITS :i. Depth i Size <br /> SUMPS i ber t <br /> ❑ Distance to-nearest: Well Foundation Properly'Line <br /> DISPOSAL PONDS ❑ <br /> I 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. s' <br /> Home owner or licensed agent's signature certifies the followin # r <br /> 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 /> : <br /> certifies the following "I certify that in the joerformande of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." t � <br /> The applicant must call for all required inspections. Complete drawing on reverse side. t <br /> Signed OILl Title: ) " <br /> Date: <br /> ! FOR DEPARTMENT USE ONLY t� <br /> r <br /> Application Accepted byii <br /> i <br /> s Date — s 19 Are; <br /> Pit or Grout Inspection b Date S <br /> t Final Inspection by 3_ Dat <br /> r <br /> Additional Comments: /`f 3Ql <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-638.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE { <br /> �/� H;PER <br /> M+ EFf 1426 fREY.t/a51 /,� //// �y� � / <br />