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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 />{f 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 Joaq <br /> Local Health District. / <br /> j [ Gze PM . <br /> r Job Addre Ity <br /> 1 ddress (%�Td Phone <br /> Owner's Name <br /> 19 <br /> ' Contracto cess License No, f hone F <br /> TYPE OF WELL/PUMP:. NEW ELL 1-1 REPLACEMENT LJDESTRUCTION El f, <br /> PUMP INSTALLATION P" SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLD. PROP. LINE ` 41 <br /> i r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS , <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> " <br /> LJ Ind trial ❑ Open Bottom-.. ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' <br /> 4rpomestic/Private ❑ Gravel Pack �❑ Tracy Type of Casing Specifications <br /> [l Public f! Other Ll Delta Depth of Grout Seal Type of Grout <br /> a, <br /> I Irrigation Approx. Depth i I E stern riace Seal Installed by <br /> H P. State Work Don <br /> Repair Work Done Ldr type of Pump x <br /> Well Destruction ❑ Well Diameter Sealing.Material Itop 501 ! <br /> i <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORT(:" NEW INSTALLATION [.1 REPAIRlADDITIOWLI DESTRUCTION I 1 (No septic system permitted if public sewer is f ' <br /> available within 200 feet.) <br /> ti \X <br /> Installation will serve: 'Residence Commercial. Other. a. 3 <br /> " Number of living units: Number'of bed"rodinsT T-y"`�" J <br /> x s Water ' - <br /> Character of soil to a depth,of 3 feet:+ ter table depth k! <br /> SEPTIC TANK,�*w '❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT.,PLT.,L1 a ...� ,� Method of Disposal <br /> 1'+ S ' 'Distance to nearest: Well Foundation Property Line <br /> i <br /> ' LEACHING LINE Cl No. & LengthF of lines Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line _..— <br /> SEEPAGE PITS I I ; Depth Size Number `'x <br /> } <br /> SSF <br /> T <br /> SUMPS p f.,iv LI—Distance toearest: Well Foundation Property tine i <br /> ' DISPOSAL f!)NDS a 4.=❑ <br /> -4n 1 hereby certify that 1-have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state.laws,.and <br /> 4 rules and,regulations of the San Joaquin,, oval Health District. - <br /> I F Home owner of 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 the rmance of the work for w is thi is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." # <br /> I The applicant must call for required ins ctions plot dra sid <br /> l Signed <br /> FOR DEPARTMENT USE ONLY <br /> [ J <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 a 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 /> FE@ AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ` ♦ 1GFi 1324 <br /> IR <br /> Mi H sY <br /> EH 14-2e <br />