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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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. �j <br /> Job Address V �Af �7� �� City `-"' Lot Size J� ��� PM -75-- <br /> Owner's Name eil1L - Address �7�7 �T��!/�� / Phone <br /> Contractor's Name /`W-W "e� :,� License No. �6767Q Phone <br /> TYPE OF WELL/PUMP: 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 �D <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/Private ❑ Gravel Pack ,---❑-TraFy1Type-of Casing----- --w Specifications <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Errigation �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 Y <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Quer •1 C� <br /> Number of living units: I Number of bedrooms _... j <br /> Character of soil to a depth of 3 feet: C Water table depth <br /> SEPTIC TANK &'—Type/Mfg tf&V <br /> YP 9 Capaclt - No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �£ <br /> Distance to nearest: Well Foundation - Property Line <br /> 4' <br /> LEACHING LINE ile-No. & Length of lines r I ) Total length/size 2 0 <br /> FILTER BED 11Distance to nearest: Well Zyof- Foundation v !!�Q­ACT' Property Line <br /> SEEPAGE PITS Depth Size { Number _ <br /> SUMPS ❑ Distance to nearest: Well_11V Foundation s Property Line <br /> .� �. <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. k <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 /> certifies the following: "I certify that in the performance of the work for khich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must c r e uire nspec' omplete drawing on reverse side. _ <br /> f <br /> Signed Title: l <br /> l"✓� � Date: <br /> i K, I I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Are <br /> 0Pit' r Grut Inspection byData Final Inspection by Date <br /> tional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 lul <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> FEE <br /> INFO MOUNT D``UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.10/83) . U <br /> EH 14-28 v <br />