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n <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T CN 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 Joaaltin Local Health District for a permit to construct and/or install the work herein described.This apptication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules ane Regulations of the San Joaquin <br /> Local Health District. / <br /> Job Address City Lot Size PM I <br /> Slrlaps S��F J�L 2 3- <br /> Owner's Name Address Phone <br /> Contfactor� Address -74'd2' 20?f 3i iT�1 ft_icItnse No. 'r7y Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION d { <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 V�}} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _ PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> INTENDED TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ID Tracy Type of Casing Specifications <br /> I'1 Public I:1 Other i7 Delta Depth o eal Type of Grout <br /> I 1 hrilfauan __Approx. Depth i I Eastern Surface Soul Installed <br /> 'i <br /> Repair Work Done 1.3 Type of Pt)mp _ 14 P. State Work <br /> Well Destruction 0 Well Diameter Sealing Material flop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIRIADDIT40 DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feel.I <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 ❑ Type/Mfg Capacity No.Compartments <br /> PKG. TREATMENT PLT.f 3 Method of Disposal <br /> Distance to nearest: Well__ Foundation Property Line <br /> LEACHING LINE No. & Length of lines �— 7t ­ Total length/size <br /> FILTER BED �i7 Distancetonearest: Welt 1 Foundation s Property Line <br /> or <br /> I <br /> SEEPAGE PI" I I Depth ---Site _ Number <br /> SUMPS I 1 Distance to nearest: Well _ Foundation Property Linn <br /> DISPOSAL PONDS E 1 <br /> I hereby certify heat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state laws,and <br /> rulr,s 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."Contractors hiring or subcontracting 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 compenria- <br /> tion laws of California." <br /> The applicant must c or all require pecti cmplete drawing on reverse side. <br /> �•yy-� ♦2- Zry7 <br /> Signed X_ ills: Data: <br /> _ <br /> V FOR D"PARTMENT USE ONLY / /7 I <br /> 2 / Area 1— <br /> Application Accepted _. Dale <br /> Pit or Grout In ion _ t)ato_ Final 1nsFaction by r Date,/17 <br /> Additional Comments: - <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 C Manteca 823 7184 0 Tracy 8356385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O, Box 2009, Stk.,CA 95281 <br /> FEE AMOUNT DUE At,tgUr+T REMITTED CnSfr RECEIVED SY DATE PERMIT NO. <br /> INFOell_7 <br /> EK:3L.�4tAFV.1—to <br /> /l <br /> V <br />