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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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.'} t <br /> Job Address Y r 7 ' rr� _ City x7 " of Size /V,5e r PM <br /> Owner's Name u/ I �J N y' '(I Address <br /> Contractor a Address �YxB 71 Rkicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE ENT ❑ 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 S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth 0 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 Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other �. f <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 IMf9 Capacity No. Compartments 2 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well A20,f Foundation P7Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well 2)r Foundation_260 "It Property Line s� <br /> SEEPAGE PITS &' Depth .�a' Size �X x- Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I 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, L shah not <br /> F 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 all required inspections. Complete drawing on reverse side. <br /> Signed XIS _..T �-- Title: —1 fig-5— - Date:3_72 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 0Z Area d ' <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-67814' ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMIITEO RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 35- <br /> + EH13-24(REV.1/65) <br /> EH 4428 /,� <br />