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APPLICATION FOR PERMIT <br /> 1 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. <br /> RJob Address City Lot Size PM <br />° Owner's Name ��1/�� Address � Phone <br /> Contract GlA ddress License No. Z zZ Phone510017— <br /> TYPE <br /> 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ v <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 Ll Tracy Type of Casing Specifications <br /> 1"1 Public Cl Other;t_ 11 Delta Depth of Grout Seal Type of Grout _ <br /> I i Irrigation __Approx. Depth 1.1 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 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION 1 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> Zcommercial <br /> available within 200 feet.) <br /> Installation will serve:_fRes'dence _ Other 7 <br /> Number of living units: Mr Number o edrooms l Q <br /> - J <br /> Character of soil to a depth of 3 feet: '• Water table depth <br /> SEPTIC TANKType/Mfgr Capacity O No. Compartments . <br /> PKG. TREATMENT PLT. l=1 ^t .{ /--�( �A f Method of Disp6sal <br /> r� Distance to nearest: Well�_-` Foundation L_ Property Line <br /> LEACHING LINE No. &Aength of lines '"" - "Total length/size A <br /> FILTER BEDS ❑ Distance-to;nearest: Well. Foundation. Property Line <br /> -> 7 K <br /> k <br /> SEEPAGE PITS l I Depth '� Size Number <br /> SUMPS ❑ Distance to nearest: Well 3 Foundation Property Line 4 T <br /> DISPOSAL PONDS 0- <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 Diltrici.-�V,,, <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 applfca ust call II r quired inspections. Complete drawing on reverse sie <br /> Signed X Title: ` Date: AA Ar <br /> FOR DEPARTMENT USE ONLY - <br /> ���� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection bybate Final Inspection by` � Date Z ~l3-c7IJ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 } <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> A5H RECEIVED BY ERMIT'NO, <br /> a EH 13-24IREV.iik51 —7a f��0 <br /> EH 14-26 /�-' 1 <br />