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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �© �00•�+ ,Y, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i. (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. 18&2 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> j. rr :Y <br /> Job Address ge City S�/��. Lot Size.1i 2 e-4 3rd PM <br /> XI� p ! <br /> Owner's Name. �1XJ71'� (r�ll1T_S Address q�/ ,�. �/����� Phone <br /> 'rC Contractor `�"�"�"'"`-Address-"""""' `' —'—'•"'�"-'-"'°'License No. —•TPhone-----_-�- 3, <br /> TYPE OF WELL/PUMP:_______.,,,,.NEW WELL,❑ WELL REPLACEMENT_0 _ DESTRUCTION ❑ w i. <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private- 19-Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('I Public ❑ Other LI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .�. _-Approx. Depth i I Eastern Surface Sual Installed by <br /> r <br /> Repair Work Done '❑ Type of Pump ff � H.P. State Work Done <br /> Well destruction ❑ Well Diamet rf I Sealing Material (top 50') ;I <br /> Depth, ' Filler Material jBelow 50'1 \` <br /> TYPE OF-SEPTIC WORK: NEW'INSTALLATION f:I REPAIR/ADDITION irl—DESTRUCTION- -fNo-septic system permitted if public sewer is ;I n <br /> f ! j vaiiable within 200 feet.) 1 <br /> Installation will serve: Residende-, " Commercial_ Other <br /> ! 6 . <br /> Number of living units: Num: ber#of bedrooms i <br /> Character of soil to a depth of131fee —1 Water table depth <br /> ,,SEPTIC TANK h p y,Type/Mf1g - Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t ,� ♦,_ ! { Method of Disposal I <br /> ` r Distance 40 nearest: Well ' Foundation ' Property Line s ;i <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> — I <br /> FILTER BED `C) Dist1#nceto nearest: Well Foundation PropertyLiner\ ?� <br /> SEEPAGE PITS. 1 I`'Depth Size Number r. <br /> s SUMPS Ll Distahce,to nearest: Well Foundation Property,Line r <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work_will.b_e_°done in-accordance-with-5an Joaquin county ordinances, state laws ;a <br /> , nd <br /> rules and regulations of the San Joaquin Local Health District. f <br /> t. 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." A1L ` <br /> The applicant must call for all required inspections. Co plate drawing on revers side. ;l <br /> Signed X Title: , Date: <br /> R D RTMENT USE ONLY <br /> \[ Application Accepted by I Date. ���� - Area <br /> k <br /> Pit or Grout Inspectio by,;, 3 Date Final Inspectionby LA&2=> {fate <br /> E ! ♦ � 1\ , <br /> Additional Comments: d \ <br /> i ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> f. Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEJ'CKINFO AMOUNT DUE . AMOUNT REMITTED eW H RECEIVED BY DATE PERM17 N0. <br /> + EH13-241REV.iiwsl <br />