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APPLICATION FOR PERMIT S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> t, \ Qa,;,� i-, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F <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 descrd. 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 Regulatibeons o1 the San Joaquin <br /> Local Health District. _�o� , <br /> Job Address � � Cit'S!``" Lot Size PM <br /> { Owner's Name <br /> t�17 �0 xl Address ' ' y� Pho <br /> 4"0 <br /> ! <br /> Contractor Address ` License No, Phone <br /> „ _TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> E DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DI D. �OP. INE <br /> I FOUNDATION: AGRICULTURE WE OTHER WELL UMPS <br /> INTENDED USElrnmorkDone— <br /> Repair <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ eca Dia. of a tion Dia- of Well Casing <br /> ❑ Domestic/Privat ❑ Tracy Type of Casing Specifications <br /> fl Public F1 Delta Depth of Grout Seal Grout - <br /> I I Irrigation pth I 1 Eastern Surface Seal Installed by <br /> I Repair Work Done H.P. State Wark Done <br /> i <br /> r <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION 1-1 DESTRUCTION iNo septic system permitted if public sewer is <br /> C available within 200 feet.) <br /> c Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ,•-W Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> M Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑. No. & Length of lines Total length/size <br /> 1 FILTER BED ❑ Distance to <br /> �nearest: ' Well Foundation Property Line <br /> SEEPAGE PITS Depth [�'" Size Number <br /> SUMPS L3 Distance to nearest: Well Foundation Property Line <br /> ' DISPOSAL PONDS ❑ <br /> l <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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m c for;all uire pections. Complete drawing on reverse side. <br /> Signed Title: /� Date:: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date Area 03 <br /> Pit or Grout Inspection Date Final Inspection by Date Arp� 3- <br /> ) 42.5 <br /> Additional Comments: ar l5 <br /> 'f 1011 �) <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 LCIS <br /> Applicant - Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CKSH RECEIVED BY DATE PERMIT NO. <br /> , 1H 13-241REV.�i851 INFO <br /> 3s' <br /> EH 14-2e <br />