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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. ' <br /> Job Address City Lot Size :e/ F13M ! <br /> Owner's Name dress Phone ` <br /> -- y h ne z <br /> Contractor Address License No Phone <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMyer ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SY TEM AIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE 4KLL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C TRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. f Well Excavation _ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack C1Tracy Typ of Casing Specifications <br /> ❑ Public 171 Other f7 Delta De th of Grout Seal Type of Grout <br /> I E Irrigation __,.Approx. Depth I I Eastern S rface 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 INSTAL TION [Ir REPAIR/ADDITEON l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Y/ available within 200 feet.) <br /> Installation will serve: Residence_ Commercial ther <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: � __'7CNa�f 1-ab[b ae—p_#i `-" ­ -_- - ` <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ��� tMethod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines 2 SZ Total length/size <br /> FILTER BED LJ Distance to YfeAret" Well Foundation �Q4� Property Line <br /> If <br /> i VSEEPAGE PITS I I Depth 2 r SizeK Nuaper <br /> SUMPS Ll Distance to nee st-. Well JS 0 Foundation /00 Property Line <br /> DISPOSAL PONDS ❑ f <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 Diktrict. <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."Contractors 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 est cal!12 I required inspections. Complete drawing on reverse side. <br /> Signed Title: __ 44�(J'7'i.�� Date: '2 [�L <br /> A. OR DEPARTMENT USE ONLY <br /> Application Accepted by •"� ;t Data Z �/ Area <br /> or Grout Inspection by Date? ` (L Final Inspection bye Date <br /> �� <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NF AMOUNT DUE AMOUNT REMITTED CA5U RECEIVED BY DATE PERMIT NO. <br /> + EH13-24iREV.I/A5) -70,v ,) f"y/r TX ♦ �� / D U —'"`� <br /> EH T4m <br />