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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 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 end/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 Rules and Regulations of the San Joaquin <br /> Local Health District. py 15 ,, - <br /> Job Address 4 ,� / 174,U/ City Lot Size PM <br /> Owner's Name Address Phone <br /> Uy v. <br /> _ConhactocLAddress PO, l=(, M�'V License Nqt Piton <br /> ,_TYPE OF WELL/PUMP: , _ NEW;WELL.❑ WELL-REPLACEMENT:❑ -_ DESTRUCTION b. - - - -PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ;DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Pul ic,'i%` 0 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Slut Installed by - <br /> t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> tri <br /> Well Desbuction ❑ Well Diameter Sealing Material top 501 r <br /> Depth Filler Material (Below 501 • <br /> TYPE OF SEPTIC WORK: NEW INSTAL AT,[ON 7 REPAIRI ADDITION>< DESTRUCTION I I iNo septic system permitted if public sewer is .97 <br /> - dyailabte,within 200 feel.) <br /> I• Instaltation will serve: Residence I!L-' Commercial_ Other, ` • a <br /> Number of living units:,. Number of bedrooms <br /> Character of sod to a depth of 3 feet �z A Water table depth <br /> SEPTIC TANK ':� 0 Type%Mfg t .-•GapacrtY' sT '''` �'� No. Compartments <br /> K- <br /> PKG. TREATMENT PLT.'[," ' :Method of Disposal <br /> - 9. _ i <br /> Distance to nearest: Well� Foundation, Property Line I <br /> LEACHING LINE No. &Length of lines 'Total length/size— <br /> FILTER <br /> ength/size FILTER BED Distance to nearest: Well 1-Foundation Property Line <br /> tie <br /> SEEPAGE PIT$ -94Depth Size ��-_� r • ''' Numb.? <br /> r SUMPS LI Distance to nearest: Well Foundation Property Line " <br /> DISPOSAL PONDS <br /> I hereby certify that I haveprepared'this application and that the work will be done in accordance with San Joaquin county ordinances,state law's-and <br /> rules and regulations of the San Joaquin Local Health District. - ! <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workmen's-compensation laws of-California:"Contractors 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 persona subject to workman's compensa <br /> tion laws of California." " <br /> The applicant must call for raqr,id in.spections. Complete drawing on reverse side. ' <br /> Signed X_ &_ IL Title: �( Date: <br /> FOR DEPARTMENT USE ONLY ' <br /> i Application Accepted by Date IS • Area <br /> Pit or Grout Inspection by DateFinal Inspeclion by Date*30 S <br /> II Additional Comments: �" 2 f <br /> 0 Stk 466-6781 ❑ Lodi '369.3621 O Manteca 823-7104 ❑ Tracy 835-6385 - <br /> Applicant- Retum all copies to: EnYrontnentet Health Permit/Services 1601 E. Haiehon Ave., P.O. Box 2009, Stir., CA 95201 <br /> FEE <br /> IAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> NT-0 CASH. <br /> I � <br /> • EH (REV.rrs s) © �— 3A O O 54 G <br />