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i� <br /> +. -� APPLICATION FOR PERMIT <br /> L HEALTH DISTRICT <br /> SAN JOAQUIN LOCA <br /> I' 1601 F. HAZELTON AVE., STOCKTON, CA ® I <br /> 09) 466-6781Telephone (2 <br /> ;� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV 15 08 <br /> (Complete in Triplicate) _ Iication is <br /> and the Rule anp�y FINERVICES in <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor r sc eV�C�Sp �I 'I <br /> Q compliance with San Joaquin county Ordinance No.549 for sewage or No. 1862 for welllpump <br /> made in camp� I <br /> Local Health District. ill - <br /> ilLot Size _ PM`—'-- E <br /> 3 Ciky <br /> Job Address - 'hone <br /> P <br /> n r Address ! <br /> Owner's Names V`''- r j I <br /> ' �.. <br /> `�`'' scense No6�- Phon <br /> Contractor EPLACEMENT ❑ DESTRUCTION ❑NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELLIPU : SYSTEM REPAIR ❑ I <br /> . PUMP INSTALLATION SEWER LINES PITS/SUMPS <br /> ��_ DISPOSAL-fLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _�� AGRICULTURE WELL OTHER WELL <br /> FOUNDATION _�--- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation <br /> ❑ ndustrial ❑ Open Bottom C5 Manteca Specifications <br /> i <br /> �Qomestic/Private ❑ ❑ Tracy Type of CasingGravel Pack Type of Grout ' <br /> ✓ ❑ Other ❑ Delta Depth of Grout Seal <br /> D Public ti <br />� � urface Seal Installed by . <br /> 1 1 Irrigation ApProx. Depth I t Eastern f 1 Stat6 Work Done <br /> Type of Pump H.P. �•- � <br /> Repair Work Done ❑ Sealing Material )top 501 <br /> l Well Destruction ❑ Well Diameter Filler Material {Below 501 <br /> Depth <br /> available within 200 feat.) <br /> TYPE OF SEPTIC WORK: NEW 1NSTALLATlON ll HEPAIRIADDITION l i DESTRUCTION l 1 (No septic system permitted if public sewer Is �I <br /> Installation will serve: Residence <br /> Commercial— Other —_-- II <br /> ':Number of living units: Number of bedrooms Water table depth <br /> '�'Character of soil to a depth of 3 feet: Capacity---- No. Compartments j <br /> SEPTIC TANK 0 Type IMfg -74 Method of Disposal I <br /> PKG. TREATMENT PLT. ❑'' I <br /> 7 Distance to nearest: Well <br /> Foundation Property Line <br /> Total length/size 'I <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> Foundation " <br /> FILTER BED 011 Distance to nearest: Well i <br /> Number Ii <br /> I SEEPAGE PITS l 1 Depth Size k Foundation Property Line <br /> SUMPS LlDistance to nearest: Well <br /> DISPOSAL PONDS � <br /> I hereby certify that I have,prepared this application and that the work will'Nbe done in accordance with San Joaquin county ordinances, state laws, <br /> rules and regulations of the San Joaquin Local Health Diltrict. work ! <br /> g: ,. <br /> Home owner or licensed agent's signature certifies the ft towiorkman'srtcompensation laws of California.rmance of "Contractor's rhir hiring or sub-contract <br /> glsign�t re II <br /> employ any person in such manner as to become subject to wo <br /> • certifies the following: '9 certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> c tion laws of California." <br /> The applicant must call for all regki speGbons. Complete drawing on�everse side. Date: . jI <br /> � # Title:,♦,,io , <br /> Signe <br /> FOR DEPARTMENT USE ONLY <br /> Area (f <br /> e t Date <br /> Application Accepted-byDate <br /> la Date Final inspection by� <br /> 1 Pit or Grout Inspection by <br /> J; <br /> Additional Comments: i <br /> ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> nvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S <br /> Applicant- Return all copies to: Etk., CA 95201 <br /> ❑ 5tk 466-6781 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> 4 FEE `AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 1 !i <br /> t.EH 13-24(REV.t <br /> EH 14-28 �' <br />