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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1 Telephone (209) 466-6781 v 7 J <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. . A- 749-- <br /> 3 <br /> Ci Lot Size PM <br /> s`� Job Addre <br /> Owner's Name C Address hone <br /> �,� x - 'Phone <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP: NEW WELL_El WELL REPLACEMENT 11DESTRUCTION 13 , <br /> PUMP INSTALLATION ❑ ;¢��� SYSTEM REPAIR El OTHER'❑ a } <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES •, DISPOSAL FLD. PROP. LINE , <br /> FOUNDATION AGRICULTURE W *- <br /> ELL' - OTHER WELL " PITS/SUMPS <br /> F-� <br /> INTENDED USE ` 'TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom E] Manteca Dia. of Well Excavation Dia. of`Well Casing <br /> ❑ Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> Type of Grout x <br /> ElPublic El Other [D Delta Depth of Grout Seal Yp <br /> ❑ Irrigation --Approx. Depth ElEastern Surface Seal Installed by R , <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ' l <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 Q <br /> Depth Filler Material (Below 501 <br /> ITYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION E3DESTRUCTION L3 (No septic system permitted if public sewer is <br /> �� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other m (Z 6A-O � , <br /> Number of living units: Number bf bedrooms <br /> Character of soil to a depth of 3 feet: a t Water table depth <br /> SEPTIC TANK /—Type/Mfg i Capacity Z�© No. Compartments 2� <br /> PKG. TREATMENT PLT. CJ �� Method of Disposal <br /> Distance to nearest: Well foundation —1 �'roperty Line / <br /> f LEACHING LINE No. & Length of lines Trot I length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation !� Property Line <br /> SEEPAGE PITS ❑t-Depth 1 Size Number <br /> iSUMPS ❑ Distance to nearest: y Well Foundation Property Line <br /> k 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. <br /> I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: " <br /> mpensation laws California."Contractors hiring sub-contracting signature <br /> employ any person in such manner as to become subject to workman's co <br /> certifies the following:"I certify that in the performance of the work for which.this permit isissued, <br /> ued,I shall employ persons subject to workman's compensa <br /> _ tion laws of California." <br /> Y The applicant must call for all required inspectio S. Complete drawing on re rse side. <br /> = <br /> Signed Title: <br /> t e FOR DEP RT NT US ONLY <br /> ay. �.-...- Date <br /> Application Accepted by 1 f <br /> i , - Date Final Inspection by Date L <br /> Pit or Grout Inspection-by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca 823-7104 ❑ Tracy 835-6385 <br /> ' Applicant- Return all copies to: Envirc mentWfiealth Permit/Services 1601 E. Hazelton Ave.;P.O. Box 2009, Stk., CA 86201 <br /> 1 <br /> FEE CK RECEIVED BY DATE PERMIT`N0. <br /> i INFO AMOUNT DUE AMOUNT REMITTED CASH - <br /> + EH 13.241REV.101831 ��� ��^•'� lir �- ,� ���� .—.—.... <br /> EH 14-26 —.. <br />