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APPLICATION FOR PERMIT <br /> f i <br /> SAN JOAQUIN LOCAL. IiEALTH DISTRICT <br /> 1601 E. HAZE;_TON AVE., STOCKTON, CA a j 1 <br /> Telephone (209) 466-6781 <br /> L E <br /> PERMIT EXPIRES 1-YEAR FROM DACE ISSUE <br /> (Complete in Triplicate) ovork .This hcat;on is <br /> Jna uin Local Health District for a permit n con1B6struct <br /> t andlof install and the Rules and rRegu aeons of the S n Joaquin <br /> i Application is hereby made to the San q <br /> made in compliance with San Joaquin County Ordinance No.548 for sewage or <br /> Local Health District. ty0 fycr�s PM�--- <br /> City�� Lot Size: <br /> PrIq .eSesl�.0 <br /> Job Address Phone <br /> Address <br /> t <br /> Owner's Name <br /> Address-:. License No. -�-- r. •" <br /> ,6aax . i <br /> ContractorDESTRUCTION ❑ <br /> r NEW WELL ❑ '► WELL REPLACEMENT ❑ <br /> OTHER ❑ <br /> j t TYPE OF WELLIPUMP: >• -` SYSTEM REPAIR 0 PROP. LINE <br /> PIiMP INSTALLATION ❑ DISPOSAL FLD. <br /> } SEWER LINES —. �— PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> -FOUNDATION --- f <br /> I f N 1:N� E�usl TYPES OEL� <br /> PROBLEM EM AREA EE��� <br /> STRUCTION SPECIFICATIONS Dia.of Well Casing <br /> ❑ Industrial C3 open Bottom ❑ Manteca Specifications � <br /> 4, Cl DomasticlPrivate © Gravel Pack ❑Tracy Depth of Grout Sea! Type of Grout - --- <br /> G1 Other n Delta ` <br /> (1 Public H Surface Seal Installed by <br /> I l irrigation --------- <br /> L—Approx. Depth I I Eastern' Stele Work Done <br /> I Repair Work Done L3 H.P.Type of Pump , <br /> ❑ Sealing Material stop 50 <br /> Well Destruction Well Diameter <br /> '1 , <br /> pepth Filler Material IBelow 50'! <br /> c sy <br /> i TYPE OF SEPTIC WORK: ONEW INSTALLATION REPAIRfADDiTtON l I DESTRUCTION.! l aIND <br /> ailabpe1withine200 feet.) <br /> if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: W ## Number of bedroomsSBD I <br /> f Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Cl Type/Mfg CI f� Capacity ��a No. Compartments <br /> PKG. TREATMENT PLT.d ,A�� Method of-Disposal <br /> i <br /> Distance to nearest: Well-��O Foundation Property Lina <br /> s _ <br /> r LEACHING LINE I? No. 8 Length of Lines y0 Total length/siz`e�� <br /> 'FILTER BED 0 Distance to nearest: Well 044 r „Foundation Property Line <br /> r I �'. <br /> ,r SEEPAGE PITS f!I Depth A5" Size t ��!� ���' t Number q� <br /> SUMPS Lil Distance to nearest: well)/,94p,* Foundation Property Line - <br /> DISPOSAL PONDS W r <br /> I hereby certify that-I•have prepared•this•dpplication and.that the work will be done in accordance with San Joaquin county ordinances, state laws, and C <br /> rules and regulations of th'e San Joaquin`Lacal Health Di3trict. <br /> Home owner or licensed s6ent'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 Califomia."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 /> J The applicant mus rail fpr all required inspections. Complete drawing on reverse Side. <br /> Signed , I Title: Date: <br /> �JJ <br /> FOR DEPARTMENT'-USE ONLY 7 <br /> Application Accepted by R Date Area <br /> Pit or Grout Inspection by r Date Final Inspection b3> <br /> W Data <br /> Additional Comments: <br /> ❑ Stk 466.6781 It Lodi 364-3621 ❑ Manteca• 923-7104 ❑ Tracy 835-6385 <br /> Applicant- Retum all copies to: Environmental Health PArrNt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 <br /> 4 1 <br /> PEE INFO IkWOUNT DUE MOUNT REMITTED CSD RECEIVED BY DATE P£RM17'NO. <br /> 3.24' <br /> CHI {REV.i i w 51 I S r�� /'.' fKJ <br />