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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address � f. . %�d/ �-'rK City G Lot Size �CJ PM <br /> Owner's Name _, ����°r Address 720' Phone <br /> Contractor <br /> Address ��` < License No. Phone <br /> TYPE OF WELL/PUMP: , NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTA-LLATiON D SYSTEM-REPAIR-C]- �, OTHER C1 <br /> DISTANCE TO.NEAREST: SEPTIC.TAN.KSEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION'_ } ,r '"AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t: ❑ Industrial ❑ Open Botfom ❑ Manteca -,Dia, of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 171Other J F1 Delta­f Depth of Grout Seal Type of Grout <br /> z tt <br /> I 1 Irrigation Approxi Depth I i Eastern, � Surface Sea] Installed by - <br /> Repair Work Done ❑ Type of Pump H.P.* - `-State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') , <br /> f <br /> - Depth I ' Filler Material /Below 50'1 a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIR/ADDITION I I DESTRUCTION I^1,iNo'septic system permitted if public sewer is <br /> y.. - available within 200 feet.) <br /> Installation will serve: Residence Commercial Other ), I <br /> Number of living units: Number of bedrooms _31 _ r_ <br /> Character of soil to a depth of 3 feet4�4 /ti F? - ` f Water table depth <br /> SEPTIC-UNK- �D Type/Mfg p� j—, Capacity' G.� No'Compartments <br /> + s <br /> �Y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> """ � <br /> ;. Distance-to nearest: Well Foundation Property Line .RD . <br /> LEACHING LINE No. & Length of lines 4/j Total length/size <br /> , <br /> FILTER-BED ❑ :Di's tanceAto�nearest: " Well ' '� Foundation s��� Property Line t�O <br /> i, SEEPAGE PITS 11 Depth Size — Number i <br /> I. SUMPS ❑ Distance-to nearest: Well --fotmdation"" "°"�"-- --I;Iroperty,Line <br /> DISPOSAL PONDS ❑ <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. ; 't <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perforrn3 a df the work for which this permit is issued, I shall not <br /> ' employ any person in such manner as to become subject to workrriah's'compensation laws,-.of.California." Contractor's hiring or sub-contracting signature <br /> I 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." It <br /> a The applicant must call fora required inspections. Complete drawing on reverse side. re <br /> Signed X Title: Date: <br /> a F, DEPARTMENT USE ONLY <br /> { <br /> Application Accepted by Date, Area , <br /> / Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> f ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Traby 1 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., f.O. Bax 2009, Stk., CA 95201,.- <br /> 1 4 r <br /> AMOUNT DUEAMOUNT REMIT <br /> " TED CK RECEIVED BY. <br /> FEE <br /> -INFO- --._� CAS1i <br /> +.EH 13-29 IREV.1/145) �+ <br /> EH 14-28 Q <br />