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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA rvo <br /> Telephone (209) 466-678104 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate). . 4 <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 —. Cit S 8nJ PM <br /> Y 760--- � _ Lot Size C <br /> Owner's Name E SEW Address 47z A g K c home 2q A—0 3 <br /> Contractor Address License No. <br /> Phone <br /> TYPE OFWELL/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 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 Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingk <br /> Specifications O <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout SealI <br /> Type of Grout <br /> ❑ Irrigation --4ppr0x.,.DeptI ❑ Eastern ' Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well DiameierSealing Material (top 50') <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence i Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mig I <br /> Capacity <br /> PKG. TREATMENT PLT. C1 No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No_ & Length of lines T R Total length/size <br /> FILTER BED ❑ Distance to nearest:- <br /> F.r Well Foundation Property Line F <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ - Distance to nearest: Well Foundation Property 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. <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 fn�Ilrequ'�odinsp�ectkons. �Complete­drawing on reverse side. <br /> Signed Title: 45j 2 7- g- -7 <br /> Date: _ <br /> tMante <br /> OR DEPARTMENT USE ONLY 2 <br /> Application Accepted by Date ~a r" Area <br /> Pit or Grout inspection Final Inspection by Date # <br /> Additional Comments: <br /> t ��� t <br /> ❑ Stk 466-6781 . ❑ Lodi 359-3621 '' ❑ 823-7104 ❑ Tracy 835-11385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO SH DATE PERMIT•NO. <br /> + EH1 -24fREV.>ix51 < of <br /> EH 142$ <br /> d <br />