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APPLIC4TIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1e �� 1601 E. HAZE T ON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r _v 1988 <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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of:th <br /> ­01 Lll . "S' 'J <br /> oa -R' <br /> � <br /> Local Health District. /SERVICES <br /> K59 a <br /> ;I�L <br /> Job Address y Lot Size PM <br /> Owner's Name Address �L: Q Phone <br /> Contractor . Addres t tJ✓ License No;3Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES < DISPOSAL FLO. 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 pia. of Well'Excavation Dia. of Well Casing <br /> FKDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 171 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation �-_Approx. Depth I Eastern Su ce Seal Installed by 04 4=11 <br /> Repair Work Done i Type of Pump _.._ H.P. State Work Done A <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'i REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth ("� <br /> SEPTIC TANK LJType/Mfg Cap acjty No. Compartments 4 <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � +rvJJJ <br /> i \J <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Q Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ] Depth Size �_..__.T Number <br /> SUMPS 0 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, 1 shall employ persons subject to workman's compens <br /> tion laws of California." <br /> The ap 'ant mu call for all require spectio . Com a drawing on Ze side. }/ Q <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 i I c -�LC� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 4 <br /> ASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24(REV.5/1155s <br /> EH 14-26 � <br />