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APPLICATION FOR PERMIT <br /> I " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> k PERMIT EXPIRES TYEAR 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 l�=_� <br /> City_S_� t Size PM <br /> Jeb Address �/A� <br /> ` Phone ~7047 <br /> Owner's Name dress <br /> Contractor <br /> Y Address _ f License No. Q Phone <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ Dy— <br /> WELL REPLACEMENT 11 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' 0 Tracy — Type-of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Specifications <br /> l� Other C1 Delta Depth of Grout Seal Type of Grout —` —" r <br /> i'1 Public _ <br /> I I I irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by <br /> 3 <br /> I H.P.- <br /> State Work Dane <br /> Repair Work Done Ll Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> fJ <br /> Depth <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REP --ION 1W7DESTRUCTION I i INo septic system permitted i( public sewer is <br /> available within 200 feet.) �_- <br /> 1 R Installation will'serve:''Residence �ommercislT, <br /> Number of living units: Number of bedrooms I " <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC Capacity_f ._._ No. Compartments <br /> EPTIC TANK I <br /> t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> � - <br /> Distance to nearest: Well Foundation Property.Line <br /> ++, p <br /> f. LEACHING LINE ❑ No. &Length of lines Total length/size <br /> " FILTER BED ❑1 Distanrce to nearest: Well MFoundation Property Line _ <br /> SEEPAGE PITS ; :> I i Depth Size Number <br /> SUMPS Cl DistanR ce to nearest: Well Foundation Property Line FFF <br /> DISPOSAL PONDS ❑ <br /> ] nd that the work will be done in accordance with San Joaquin chunty.ordinances, state laws, and <br /> I hereby certify that I have prepared this application a <br /> r , rules and regulations of the San Joaquin Local Health District. <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 /> jemploy 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'wirkifor-which this permit is issded. I shall employ n`s persosubject-to workma`n'a compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Si ned Title: Date: <br /> g <br /> No` gY'^�' 1]'�I',S FOR DEPARTMENT.USE ONLY a F <br /> Application Accepted by Date ` Area Qac <br /> PitorGrout Inspection by Date Final Inspection by Date '� D <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 95201 <br /> FEE CK RECEIVED BY PATE PERMlT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED �Ju <br /> . �r.EH 13-241REV,I/N5) JIMO• ^1_i <br /> -EH 14-28 ^+ :r <br />