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., APPLICATION FOR PERMIT( <br /> yy SAN JOAQUIN LOCAL HEALTH DISTRICT € <br /> 1601 E. H�'ZLti lJN A+VE:, STOCKTOEV, CA I <br /> Telephone(209) 466-6781 t`> <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � r ry <br /> (Complete in Triplicate) S.r i� ' 1a3J pp <br /> Application is hereby made to&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 Joh'quip County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules anr[ µtit+or (A"IS14EMPI <br /> Local Health District. ! Iylilii7jVSERVICE$, <br /> Job Address4av ­1 Rj <br /> City ize PM <br /> 4.S>1ak <br /> Name �' Address ✓ Phone 6 <br /> Owners � <br /> .i. <br /> Contractor 1J1. Address r Q �+ License No. �Z r Phone <br /> TYPE OF WELLIPUMP: IN, N W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ fl <br /> PUMP INSTALLATION l� SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /. <br /> INTEN10ED,kJSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> Ag-ndustrial r"'L ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 1-5 Gravel Pack L1 Tracy Type of Casing <br /> Specifications `/� ` <br /> 1`1 Public ❑ O``ther F1Delta Depth of Grout Seal Type of Grout ✓, }—.. <br /> I 1 Irrigation ip..Approx. Depth I 1 Eastern Surface I Installed by <br /> Repair Work Done 11Type of Pump H.P. L _ State Work Done <br /> rtr ! <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> - •Depth Filler Material IBe{ow 50') --- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> i available within 200 feet.I i <br /> Installation will serve: Residence— Commercial— Other <br /> *j. <br /> Number of living units: ___jL <br /> Number of bedrooms j <br /> Character of soil to a depth 11 f 3 feet: Water table depth <br /> SEPTIC TANK VJ0• *Type/Mfg, ;-�. Capacity No. Compartments <br /> i I <br /> 0 <br /> r-'?'KG TREATMENT PLT._•❑rY.if= �_.�.�� - �-{ w- Method-of-Disposal - —lI <br /> Distance to nearest: Well) Foundation Property Line <br /> LEACHING LINE ❑ tiNo. & Length of lines Total length/size ' <br /> FILTER BED ❑ "Distance to nearest: Well Foundation Property Line 3 <br /> SEEPAGE PITS t 1 Depth Size Number } <br /> SUMPS ❑ 'I distance to nearest: Well Foundation Property Line Ik <br /> j DISPOSAL PONDS ❑ I y <br /> i <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 Di?:trict. <br /> Home owner or I' is signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not ' <br /> ` employ any p son in such m nor as to become subject to an's co 'onsation laws of California." Contractot's hiring or sub contracting signature <br /> certifies the ollowing: "I certify hat i the 6porforgmace of e w k for w ch this r it is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California.- <br /> The appli ant must all for I re ired insple n on r <br /> Signed X ir <br /> Date: <br /> FO =DRTMENT USE ONLY <br /> Application Accepted by 'I Date Area <br /> �2� <br /> Pit or Grout Inspection by �� bate Final inspection by / �� — <br /> Date <br /> kl <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lo`di 369-3621 ❑ Manteca •823-7104 ❑ Tracy 835 63$5 <br /> Applicant- Return all copies ito: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO „ <br /> i.EH 13-24 IREV. n 51 �3 <br /> EH 1428 <br /> 'll • ` <br />