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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 5 h <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED <br /> .IComplete 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 /> I made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 186'1 for well/pump and the Rules and.Regulations of the San Joaquin <br /> Local Health District. : V . <br /> 3Q/!0 .,; • .�'T Q(?Irfn�T r��* y _ City�- Lot Size .�Q F)C��� PM <br /> Job Address - . <br /> i. Phone 4 <br /> Owner's Name R 1^� 'o Address ._� <br /> Contractor's Name l' jSQ ix j?K-6Q& License No.42Ca 6-.r Phone "�Lj <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1:1 SYSTEM REPAIR'❑ T OTHER C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE§/_+ + � DISPOSAL FLD. - __J!RO?._LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARIA CONSTRUCTION SPECIFICATIONS <br /> El Industrial EJ Open Bottom ❑ Manteca Oia.of Well Excavation Dia. of Well Casing <br /> �` <br /> ❑ Domestic/Private ❑ Gravel pack �� D Tracy �Type�1 t:of�Ca}ng Specifications <br /> F-1PublicEl Other f] Delta Depth; of Grout Seal Type of Grout <br /> 0 Irrigation Japproz Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type o Pump H.P.n- State Work Done Q' <br /> rl <br /> Well Destruction ❑ Well Diameter Sealing Material-ftop 50'1 <br /> Depth Filler Material IBeIoU50') j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (REPAIR/ADDITION [� DESTRUCTION_❑ (No "septic sy3tem permitted if public sewer is <br /> ' '�, 7evailabie with" 200 feet.) <br /> installation will serve: Residence I— Commercial_ Other � s <br /> Number of living units: Number of b BroomI-I ..� <br /> Character of soil to a depth--of 3 feet: —Water table depth.4 <br /> SEPTIC TANK CK Type/Mfg - Capacity / D� 4 o. Compartments <br /> PKG. TREATMENT PLT. ❑ r f Method of Disposal11 <br /> 'Distance to nearest: Well Q Foundation— PropertALine .0 <br /> i - <br /> LEACHING LINE 15, No. & Length of lines r Tal length/siz' <br /> FILTER BED EliDistance to nearest: Well°/O 6. Fbundationl -t Prope a "'f" <br /> N. <br /> SEEPAGE PITS ElIDepth Size -y # Number ^_• tt, <br /> N t fl: , <br /> SUMPS � 'iDistance to nearest: Well Foundation � `''� Property�LineF�.+'t . <br /> DISPOSAL PONDS ❑ <br /> ' I hereby certify that l have prepared this application aiid that the work will be done in,aeaordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District: L - i- --- ---_ -� t <br /> Home owner or licensed agent's signature certifies the following: "I certify that'in the performance of the work for v ich this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's corf5pensation laws of California."Contractoes hiring or.,sub contracting signature <br /> certifies the following:"I certify that in the performance of the work or'which this permit is issued,I shail,emptoy persons subject'to workman's compense- <br /> �J tion laws of Cayornia. <br /> CA The applicant t call for aN required inspections. Complete drawing on rave side. <br /> 42 <br /> t Signed Title: �� ®..g3�'"[� �� Date: <br /> i. S e <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> t Date Area <br /> e G <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: C o <br /> ❑ Stk 466-fi781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑',Tracy 8354KM <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE"" l 0UN7 6U-e P AMOU-NT fIEMITTE17"`" CASH ""-'RECEIVED-9Y""""-'"��DATE"""- ""PERMIT`N0." <br /> t INFO-, ,.. <br /> +EH 13.24{REV.101831 <br /> EH 1426 <br />