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APPLICATION FOR PERMIT <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 /> s7y-,''7 ppliCation is hereby made to the Sari Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Y h >flade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1962 for well/pump and the Rules arid'Reguletions of t1 Stfrrdoa 'uiri <br /> n Lbcal'Health District. Yr <br /> �y �rdpbFAddress o'L f` City SAO �� Lot Size PM <br /> dOwrler's Name R •�e/r <br /> fJ Address ��� Phone <br /> ^ "'contractor s If-e l� Address t O r' License No. Phone <br /> OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCT <br /> is PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER_❑ <br /> "mrx.DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/S'UMPS <br /> - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w <br /> r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation { .oia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑`Tracy Type of Casing Specifications <br /> y Fl.Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout' <br /> I Irrigation <br /> ---Approx. Depth I I Eastern Surface Seal Installed by T <br /> Repair Work Done CJ Type of Pump H.P. State Work DAe = I <br /> Well Destruction .' };Q Well Diameter Sealing Material (top 541 <br /> - -- ----�, Depth Filler Material IBaiow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I ' REPAIR/ADDITION I 'I DESTRUCTION l 1 (No septiic.system permitted.if public sewer is <br /> a <br /> avadabg within 20016-et.); <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: -Nuinber,of`b dro s <br /> Character of soil to a 7"f3 feet: . `� - Sc.'t l�bG Water table deptli w t <br /> _ SEPTIC TANK ,E»- Type/Mfg �_ CiG G0— Capacity 1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ " ' I Method of Disposal <br /> Ry ' Distance to nearest: Well _ Foundation ! �_ Property Line of <br /> LEACHING LINE VNo. 8 Length of lines Total length/size o ' <br /> FILTER BED - ❑ Distance to nearest: Well ._� �? Foundation. C) Property Line t <br /> SEEPAGE PISS l 1Depth Size _ N�rmber <br /> SUMPS tPf Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ 4- <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 for ailre ired inspect ons. Complete drawing on reverse side. <br /> Signed X14 Title: _(/� ��� _ Date: d L <br /> .ar a* <br /> FO BART NT USE ONLY n <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection byeDatey .Final Inspection by . Date <br /> Additional Comments: <br /> .D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK f INFO CASH RECEIVED BY DATE RERMIT NO. <br /> a.EH 13-24(REV.7/n5 <br /> J �I '' ' ' <br /> EH t4-26 - Q^Z�' <br /> • J <br />