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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T ON 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 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> — f� <br /> Job Address V......_ d_� /l1 Y/'c.1// /4 City Lot Size�.... PM <br /> Owner's Name ! ddress ___ rte _.-.__----...— Phone Q3 s-C1 3 <br /> Contractor_. tel- c t C Address 1.alcr License No. - <br /> TYPE OF WELL/PUMP:--- NEW WELL D WELL_REPLA MENT U DESTRUCTION C. <br /> PUMPINSTALLATION C SYSTEM-REPAIR LI ,-' OTHER D <br /> E TO NEAREST: SEPTIC TANK SEWER LINES ___............._.....__.—_ DISPOSAL FLD. PROP. L[NE`` <br /> OUNpATION AGRICULTURE WELL ...__ __._.-_ OTHER WELD'""` PITS.SUMPS <br /> INTENDED USE TYPE OF WEL M AREA CONSTRUCTJON"SPEC�ATIONS i <br /> D Industrial C Open Bottom G Manteca I Excavation .._.. Dia, of Well Casing - <br /> t f Domestic/Private C Gravel Pack C_xcac Type of Casing.._'"�-� Specifications ` <br /> f- Public Ll Other F1 Delta Depth of Grout Seat ��- Type of Grout <br /> I I Irrigation _.__ pprox. Depth I I Eastern Surface Seal Installed by ................ <br /> _..._.....�. <br /> Repair Work f_.' Type of Pump H.P_ _ State Work Done _ <br /> Wei estruction C Well Diameter Sealing Material (top 50') __........ <br /> ..___-_..._..._........__..�_ <br /> Depth f iet Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION : l REPAIRrADD1TION DESTRUCTION I (No septic system permitted if public sewer is d <br /> f available within 200 feet) { (� <br /> Installation will serve: Residence_�!gCommercial Other <br /> r <br /> Number of living units: _ _ iNumber of bedroorns,�:3_._._ <br /> Character of sail to a depth of 3.feet: �-r Water table depth <br /> SEPTIC TANK J&_ T YMfg G'�/L ? ! Capacity zac No. Compartments l <br /> PKG. TREATMENT PLT Method of Disposal <br /> Distance to nearest: Wiffll.' Foundation _ Property Line <br /> LEACHING LINE No.,& Length of lines Total length/size r <br /> FILTER BED 0 Distance to nearest: i Well ?c-13' -'Founaatron Property Line <br /> SEEPAGE PITS I 1 Depih Size __ _ Number <br /> SUMPSL Distance to nearest: Well Foundation__- 'Property-Cine <br /> DISPOSAL PONDS D I <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 Diltrict. <br /> Home owner or licensed agent's signature certifies tll1e following: "I certify that in the performance of the work,for which this permit is issued, I stall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." 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 <br /> compensa-tion taws of California." I <br /> The applicant must call fqr all required inspections. Complete drawing on reverse side. <br /> Signed X / Q p . /r ./�:,Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ��+ z-_ Date 1 %-V Area <br /> Pit or Grout Inspection by Date Final Inspection by ->Date i <br /> Additional Comments: _._ __..........t. <br /> C Stk 466-6781 L; Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMtT*NO. <br /> ­EH 13-24{REV,r w 5i �f"� <br /> EH 11.28 V r� /..-�I •--/ <br />