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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) 466-6781 <br /> li PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> I' <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.. ►I <br /> Job Address <br /> City Lot Size � � PM <br /> Owner's Name Addressa 14�02 �J. r Phone d <br /> Contractor-�Q Q / r <br /> Address D t``o t f License No. Zb Phone `� 10 <br /> TYPE OF WELL/PUMP:. Il NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST'SEPTIC TANK SEWER LINES =DISPOSAL'FLD, PROP. LINE - = - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �•' <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type'of Pump H.P. State Work Done <br /> Well Destruction ❑ Well'Diameter Sealing Material (top 501 <br /> Depth er Material (Below 50') �I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAI /ADDITION K DESTRUCTION [ I (No septic system permitted if public sewer is <br /> II available within 200 feet.) <br /> ii i <br /> Installation will serve: Residence� Commercial Other <br /> Number of living units: Number of a rooms 3 <br /> Ov <br /> Character of soil to a depth of 3"feet: Water table depth 10 t <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> r Method of Disposal <br /> Distance to nearest: Well Foundation Property Line T <br /> LEACHING LINE D"'No. & Length of lines ><- '' 0 . <br /> Total length size <br /> FILTER BED ' ❑ Distance to nearest: Well c. r <br /> Foundation�_Q ,..•-,property Line_ �•_' <br /> :r - <br /> SEEPAGE PITS Depth � Size _t '~ Number <br /> SUMPS ❑ D;' ance'.torriearest: Well " z '4= <br /> _Qs `--Foiirrdation= ( == Property Line <br /> -- �.' -.•a.. :. ,;- <br /> DISPOSAL PONDS ❑ I� <br /> �l.hereby certify that I have prepared this application and that tf a work will be done in accordance'with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San"Joaquin Local-Healih District. r <br /> Horrie,owrierfor licensed agent's;srgnatFre•certlfies the following: "I certify,that in the performance of'the work-for which this permit is issued, I shall not <br /> certifies the person <br /> liowinn such manr;as'to become subject to workman's compensation laws of California."Contractor's"hiring or sub-contracting signature f <br /> g: "1 certify that in the,.performance of the-work forwhich'"this permit is-issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C;liforriia.� , ,r. _ <br /> The applicant st call for equi ed inspections. Complete drawing on reverse si <br /> w•Signed X - - .. � -�� <br /> -Title a Date: Q 4 <br /> i <br /> FOR D PARTNIENT USE ONLY <br /> 'A"p'plication Accepted by w �D SLP�p 7` Area Z- <br /> �� / <br /> 6p, <br /> or Grout Inspection by %;:Date` �f0 Final Inspection by Date <br /> Additional Ccmments:se <br /> ❑ Stk 466-6781 :;. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental'Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk!, CA 95241 <br /> EE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> I r EH 13-24 rREV.i/w51 : ;�.. Vq <br /> EH 14-28 p, y <br />