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APPLICATION FOR PERMIT ' <br /> t ,F SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 41 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/pu.mp and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> VS A City Lot Size PM <br /> Job Address 9 <br /> U e O Address � Ph°e x'77 <br /> Owner's Nam//e�� ,✓/ ,� //� <br /> Contractor CO ! Address S� Ot (Itl License No�� ]a� Phone3 fO <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ElSYSTEM REPAIR CIOTHER ❑ <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 c, <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 7 <br /> Cl Domestic/'Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public F Other Cl Delta Depth of Grout Seal Type of Grout _- <br /> I I Irrigation t _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION W° septic system permitted if public sewer.is <br /> available within 200 feet.) f '--.2 , <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: __L Number of b drooms 3 940r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 2- <br /> SEPTIC TANK ElType/Mfg e6i a is Capacity 1&610 No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,m^ Method off ,Diissppoosal <br /> D <br /> Distance to nearest: - Well /D Foundation IDI Property Line l 0o , <br /> - }• . 0 f Notal len th/size f <br /> LEACHING LINE ff7 No.-& Length of lines 9 <br /> FILTER BED I 9# ❑w:Distance-to nearest:. - Well - Q t Foundation �� r ' Property;Line <br /> SEEPAGE PITSDepth Size /Number <br /> SUMPS D Distance to nearest: Well F Foundation O r Property Line <br /> DISPOSAL PONOS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county brdinanc ' , state laws, and <br /> rules and regulations of the San Joaquin Local HeakfiDistrict.� I e r+ ., <br /> Home owner or licensed agent's signature certifies the following: "I_certify,that in the performance of the work for which this peri�riit 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 of sub-contracting,�ssi6nature <br /> certifies the following: "I certify that in the performance of the work f_or w_hich this permit is issued, I shall employ persons subject to workman's'compensa- <br /> tion laws of California." ` <br /> The applicant ust call f r all quired inspections. Complete drawing on reverse side. <br /> Signed X 1 Title: &todee Date: <br /> FOR DEPARTMENT USE ONLY --t <br /> Application Accepted by Date r Z Area L <br /> f t <br /> Pit or GroutInspection_- M�fate_ F,inal_In p ction.by Date r <br /> [D1/Gr Q 3L�S �iP S 0 <br /> Additional Comments: a � � `- '- � ' �'""` � <br /> i EJStk 466-6781 LILodi 369-3621 ❑ Ma teca 823-7104 ElTracy 835-6385 !< <br /> F <br />' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 Mme/ 9 rr� <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. All <br /> INFO i CASH <br /> f + EH13-24(REV.I/115) , p v r`00-? <br /> 4 EH 1I-26 <br />