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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> • 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T 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/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address cirvkK) Lot Size IZC3 PM <br /> ��]7 t <br /> Owner's NamaA' 04-AC- 4iY1 (/r+� AddressX /� () .�0 ��O Tjnr�-R�yr Phone 11 <br /> �f— \ <br /> Contractor Address License No. Phone <br /> TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Prlvaie ❑ Gravel Pack ❑ Tracy Type of Casing— <br /> El❑ Public ❑ Other ❑ Delta •Depth of Grout Seal ^r7 <br /> 11 Irrigation _p Type of Grout, <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by ` t <br /> s <br /> State Work done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destructbn ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below Sly) v 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION O DESTRUCTION ❑ Mc septic system permitted if public sewer is <br /> Installation will serve; Residence 4-- Commercial_ Other available within 2DD feet.) <br /> • Number of living units:-__ Number of bedrooms <br /> Character of soli to a depth of 3 feet: - Water table depth <br /> -SEPTIC TANK Type/Mfg <br /> :r . .. paciN No. Compartments <br /> PKG. TREATMENT PLT. G7 / Method of Disposal <br /> Distance to nearest: Well T'�U Foundation Property Une <br /> J <br /> n <br /> ,.._d LEACHING LINE r$/, No. & Length of lines <br /> Total length/size <br /> �FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> 1 <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well FoundationPr <br /> DISPOSAL PONDS ❑ Property Line <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 /> certifres 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 /> The applicant r�uf�ca14{o I r quirad inspections. mpl drawing an reverse side. <br /> nt / p <br /> Signed X Title; Data: <br /> oils Date: <br /> FOR DEPARTMENTT/l USE ONLY <br /> Application Accepted by <br /> Dare 'y Area <br /> Pit or Grout Inspection by DJV <br /> ate Final Inspection by Date's <br /> i <br /> Additional Commentspu Vy� y�� <br /> ❑ Sdc 468'6791 ❑ L I 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I '. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2Dog, Stk., CA 95201 <br /> • FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECFJVED BY DATE PERMIT NO. <br /> .ER;324(REV. /851 <br /> EX/4ffi <br />