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f <br /> APPLICATION FOR PERMIT <br /> ,I SAN JOAQUIN LOCAL`HEALTH DISTRICT <br /> 'i 1601 E. HAZELTON AVE.,-STOCKTON, CA <br /> II Telt:phone,(209) 466-6781 <br /> PERMIT EXPIRES 'I-.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 a compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pum <br /> p and the Rules and Regulations of tfie San Joaquin <br /> Local Health District. f _ ' +li:�' • <br /> �� City � Lot Size PM <br /> Job Address <br /> u _ S ,m Phone - <br /> Owner's Name Address <br /> - o +,l 3 Phone 8, sk. V <br /> ' Contractor <br /> ic1 f1, Address 3� "`—' � License No. <br /> OF WELL/PUMP: !! NEW WELL ❑ <br /> WELLtREPLAGEM NT ❑ DESTRUC710N ❑ <br /> PUMP INSTALLATION ❑ $YS�EM;REPAIR ❑" ;� OTHER,❑ <br /> DISTANCE TO NEARE TIC TANK <br /> SEWER LINES`' s DISPOSAL FLD. PROP. LINE 6 <br /> FOUND AGRICULTURE WELL OTHER WELL—.PITS/SUMPS <br /> INTENDED USE !TYPE OF WELL P AREA �C?NRUCTION SPECIFICATIONS <br /> Well Excavation Dia. of Well Casing <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Specifications <br /> ❑ Domestic/Private 5 Gravel Pack 11 Tracy <br /> Type of <br /> ❑ pelta Depth-of Grout Seal Type of Grout-- <br /> ❑ Public 0 Other <br /> rox. De th ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation r�APP p State Work Done <br /> Repair Work Done ❑ Type of Pump H? f <br /> i Well Destruction ElWell Diameter Sealing Material {tap 501 I ) <br /> Filler Material (Below 50 <br /> Depth <br /> TYPE OF SEPTIC WORK: IlNEW INSTALU4TION.,❑ REPAIR/ADDITION , i�TRUCTION ❑ (No septic system permitted if publicwer-iso <br /> ' --- --availan 20 <br /> ble withi0 feet.) <br /> .ii.. I <br /> Installation will serve: Residence )C <br /> ) ommercial_ Other s <br /> a Number of living nits:'Number of bedrooms�_, <br /> - , D�s <F. Water table depth <br /> Character of soil to a depth of•3 feet: No. Compartments <br /> E SEPTIC TANK ❑ Type/ <br /> il+lfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. i❑ Pro a Line f <br /> �1I Distance to nearest: ) Well Foundatio�n� -. P rtY <br /> & Length of lines _ Total length/size <br /> LEACHING LINE € ""� 'property Line ' r <br /> FILTER BED, O Distance to nearest: Well Foundation <br /> I <br /> ' Size j Number <br /> SEEPAGE PITS Depth ,.; -+ I <br /> Foundation Property Line <br /> SUMPS El Distance to nearest: "Well Foundation <br /> � � � s/y. 3�"t✓ s <br /> DISPOSAUPONDS ..� ❑ r"� ' <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 /> 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 /> ce7ffles the following: " ertify that in the performance of the work for which this permit is issued,I shall employ persons subject to workma 's compensatiof California." !' ' ; 1Thpplicant st c It <br /> tsf all vire inp tions. _ drawing on re erre 8id --�"�' <br /> Date: <br /> Signed �.� _w —•-- <br /> FOR DEPARTMENT USE ONLY <br /> ' Date Area <br /> Application Accepted by' <br /> y i <br /> Z Z� ' Date. Z. Z <br /> Date J* Final Inspection by _ <br /> Pit or Grout Inspection by <br /> Additional Comments: �� � �� <br /> { <br /> 1 1 <br /> ❑'Stk= 466-6781 D Lodi 369-3821 ❑ Man teca x•823 7144 ❑ Tracy` ; <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., A 95201 ) <br /> C <br /> FEE PAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFOf <br /> eri,szo ISEv., 85: ca• to o to r,f �15b <br /> EH 1428 I <br />