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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) 466.6518! 4A—­ LNO'.Q <br /> > 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 Joaquin <br /> Local Health District. ,�! <br /> Job Address _ �+y l{ Par 40 <br /> ` <br /> —v City f Lot Size Q� PM <br /> Owner's Name Address ` �U(Jr� _ Phone <br /> Contractor, Addre so� <br /> License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 RUCTION., <br /> J <br /> PUMP INSTALLATION ❑ TH <br /> SYSTEM REPAIR O 'OTHER❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL jOTHER WELLS PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO13LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> mestic/Private ❑ Gra <br /> ❑ Dovel Pack ❑ Tracy Type of Casing f I. <br /> Specifications <br /> f"1 Public l Other Ll Delta <br /> t I a � Depth of Grout Seal T <br /> I i Irrigation `: Ype of Grout _ <br /> g /r' �_App+ox:Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work pone ❑0r Type of Pump <br /> H.P. }_ State Work"Done <br /> Well <br /> iDestruction ' ❑� Well Diameter Sealing Material (top 50'1 ; <br /> F Depth = .� „r Filler Material (Below 50`1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ 1yOther <br /> Number of living units: Ntum r <br /> her of bedroom <br /> s <br /> I Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> Type(fNfg —:Capacity_��D— No. Compartments <br /> p PKG. TREATMENT PLT. ❑ ) , ' '1 I � <br /> l F � + � ! } � Method off cDis�po`sal <br /> ( Distance to nearest: Well _ Foundation`�� 4 _ �-(� <br /> { w—_ Property Line _r <br /> LEACHING LINE 1 <br /> 4 No. & Length of lines Total length/size –���' I <br /> FILTER BED ❑- Distance to nearest 1Nell [t_1�! Foundation_-� <br /> 17-0 <br /> _opI y Line <br /> 77!3 1 f leo� — <br /> SEEPAGE PITS "N Depth Size �Foundation SUMPS Li Distance to nearest:w—.Well Q Property Line <br /> DISPOSAL PONDS ❑ ? <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:M+� �h i <br /> Horne owner or licensed agent's signature certifies the following_�I certify that in the performance of the�ork for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation Iaws 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,!shall em Io <br /> tion laws of California." �_ p y persons subject to workman's compensa- <br /> The applicant us II or al qu�e f inspect ons' Complete drawing on reverse side. <br /> Signed Title: y <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date t� <br /> �` � <br /> Area <br /> Pi ` Grout Inspection by <br /> I } ate ro Final Inspection by Date <br /> Additional Comments: t j <br /> ❑ Silk466-67810 Lodi 369-36211 ❑ Manteca 823-7104 CJ Tracy 635-6385 4 <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 -CK <br /> INFO RECEIVED BY DATE PERMIT�NO. <br /> +.EH 13-241REV.iiNs� �_�0�� <br /> EH 11-28 CX] <br />