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APPLICATION FOR PERMIT <br /> ` SAN JOAQUI�N LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> iF <br /> (Complete in Triplicate} <br /> �. <br /> Application is hereby made to the San Joaquin Local Health DistraI ct fora 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 /> Job Address 3 /03 - A, City Lot Size PM <br /> t /Y�j/�! ✓�1 - Addre S Phone <br /> Owner's Name � 11� <br /> Address License N <br /> t> � Phone,971Z <br /> i TYPE OF WELL/PUMP-, ,,-,. NEW WELL LI ., WELL REPLACEMENT ❑ DESTRUCTION Gl <br /> r 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 <br /> INTENDED USE TYPE OF WELL PROBL_EM.AREA CONSTRUCTION SPECIFICATIONS <br /> F ❑ Industrial ❑ Open Bottom r ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1=1 Other 171Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern ! Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.�� State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> ' Depth 3 Filler Material (Below 50') <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION5:Z REPAIW ADDITION I I DESTRUCTION I l INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> f Installation will serve: Residence Commercial then <br /> Number of living units: 4— Number of bedrooms J_ f �3 <br /> -f <br /> Character of soil to a depth ofx3 feet: _(j � ��- .Water table depth <br /> SEPTIC TANK ❑ IType/Mfg _ OL j' - Capacity .- No.'Compartments <br /> PKG. TREATMENT PLT. ❑ anla�, c Method of Disposal <br /> i Distance to nearest- Well, d1' Foundation Property Line <br /> .1 <br /> LEACHING LINE El No--9 Length of`lines f �r r ' `Total length/size <br /> i. <br /> FILTER BED 01,'-10istance to nearest: Well �roundation � Property Line <br /> SEEPAGE PITS l I Depthi Size 1 <br /> -Number h <br /> SUMPS L1 Distance to nearest: Well dP Foundation Property Line <br /> i DISPOSAL PONDS ❑ , 1 <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 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 /> l employ any person in such manner as to)become subject to workman's cdi pensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the'"rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." s ' 4 & — <br /> The applicant must call fo all required inspections. Complete.dr1.awing on reverse side. <br /> Signed X ^JyTitle. " Date: <br /> - '11 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> l <br /> Pit or Grout Inspection by Date �I Final Inspection by // 'Date Ncu� <br /> o1 <br /> 3 Additional Comments: 1 <br /> j ❑ Stk 466-6781 ❑ Lodi- -369-3621— CI-Manteca 1823-7104 L1 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �i r <br /> FEE AMOUNT_DUE -- T AMOUNT REMIT ED SASH�- EC£IVED BY""'`"� DATE­ <br /> --INFO , " "'1" PEFlF7[I7`Nt3. <br /> r _ r <br /> a.EH 13-24IREV.t/r;sI .. <br /> EH 14-28 <br />