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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Corntete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Heakh 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 /> CJI;/ lk '- �%r,C/�.e �l� L ..r.l <br /> Job Address �, �� � itY Lot Size LPM <br /> wOwner's Name S ( r�/ Address JY/a 7r LGLf <br /> Contractor Address License No. Phone <br /> TY ELL/PUMP: F NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOLIN DAT AGRICULTURE WELL + OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type Y YP o Specifications <br /> © Public ❑ Other ❑ Delta' Depth of Grout+Se Type of Grout Q <br /> C] Irrigation --Approx. Depth EI Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump' H.P., State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth er Material Be w 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAI ADDITIC.. DEST— RUCTp _jNo septic system permitted if public sewer is ! <br /> available within 200 feet.) d <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: - <br /> p Water table depth � <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �y <br /> PKG. TREATMENT PLT. ❑ <br /> • Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance tc nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: 1 Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> rI,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 /> ules and regulations of the San Joaquin Local Health District. ;I <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 applica,t must call for all requir d inspecti s. Complete drawing on reverse side. - <br /> Signed Title'r 9 P <br /> Date: <br /> r FOR DEPART NT.USE ONLY <br /> Application Accepted by <br /> Date Area <br /> / Area v 1 <br /> (� p � <br /> P.it or Grout Inspection by *1 -13W621 <br /> -- e_44_�Alv <br /> ate Fi al Inspection by . Date -� TA <br /> Additional Comme �❑ Stk 466-6781 ❑ L ❑ Manteca` -7104 ❑ Tracy 835-&385 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> d <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIVNO. <br /> INFO / CASH <br /> + EH14281REV.t/e51 �7 ��-� <br />