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.` APPLICATION-FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM.DATE ISSUED <br /> T •. ,;. � v- *.(Complete in-Triplicate), - .r �• <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:ahe Rules and Regulations of the San Joaquin <br /> P Local Health'District. "t <br /> Job Addres <br /> sizef�PM <br /> Owner's Name _ f� r�4ddress�Z <br /> w —��_— Phone <br /> Contractor d f V E _Address <br /> tr License No. Phone <br /> TYPE 4F WELL/PUMP: NEW WELL ❑ ? ;. WEL: REPLACEMENT..❑ DESTRUCTION ❑ <br /> _ PUMP INSTALLA7ION. Ot. �. i` <br /> SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> . D1SP0$AL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> EF <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ype.of Casing <br /> ❑ Public Specifications <br /> ❑ Other ❑ Delta _ Depth,of Grout Seal <br /> ❑ Irrigation _..__Approx. Depth ❑ Eastern � !,'-Surface^Seal Installed by r � Type of Grout <br /> Repair Work Done ❑ Type of Pump H.P. ___ <br /> State Work'-Done) <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> r ae4 <br /> Depth Filler-Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (NO Septic system permitted if public sewer <br /> Installation will serve: 'available within 200 feet.) <br /> Residence Commercial— ,Other <br /> Number of living units: - Number'of bedrooms ` I-Water <br /> taCharacter of soil to a depth of 3 feet: :.ble depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg 6 Capacity tINo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well �Y"'"""�oundafio Property Line u." <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER .BED ❑ Distance to nearest:- Well Total length/size <br /> Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> Number j <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS El Foundation Line <br /> Y <br /> 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 /> 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, 1 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 t call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: l- <br /> - Date: <br /> ` P SE ONLY <br /> Application Accepted by Date <br /> Area Q <br /> Pit or Grout Inspection by Date Final Inspection"by y �y <br /> ff Date <br /> Additional Comments: F �D ro <br /> ❑ Stk 466-6781 ' Ll Lodi 369-3621 ElManteca. 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 AMOUNT DUE, AMOUNT REMITTED <br /> INFO A RECEIVED BY DATE PERMIT'NO. <br /> + EH t3-24iREV.t <br /> EH i14-N2s V 3 y3 y� 5>7- <br /> - - �. k� �` rw,\ Y 7_ <br /> � r✓�.r r <br /> J <br />