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APPLICATION FOR PERMIT l L� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA " > <br /> ! Telephorte (209) 466-6781 <br /> l 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 welUpurnp and the Rules and Regulations of the San Joaquin <br /> Local Health District. Q y A r_ <br /> Job Address q 1 T} -:TA C V i �'vE City TO of Size PM <br /> Owner's Name &41� ��" c9> �N4ddress � Phone !`i J'077�. ; s g f --- <br /> Contractor?�10oe` �� -2 Address LVPW,.? License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL.❑ WE L REPLACEMENT DESTRUCTION ❑ <br /> ---;- —""""'�""`PUMP-INSTALL:ATiON.,n .STEM-REP �O .Y—^- OT-HER..❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATION * AGRICULTURE L OTHER WELL PITSlSUMPS <br /> I INTENDED-USE-- ,;, -TYPE OF WELL .y PROBLEM AREA CON CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C1 Manteca D of We Excavation Dia. of Well Casing <br /> 1 ❑ Domestic/Private ❑ Grave! Pack �❑ Tracy ype of Casi Specifications <br /> i`l Public Cl Other �n Delta Depih of,Grout eal Type of Grout _. _- <br /> I ] Irrigation ---Approx. Depth l I Eastern Surface Seal Insta d by <br /> { Repair Work Done ❑ Type of Pump P. State Work Done <br /> a <br /> Welt Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth ` ' -.F.iller_Mater+al-(Below 50'1 _ <br /> 1t TYPE OF SEPTIC WORK: NEW INSTALLATIONI I REPAIR/ADDITION I I DESTRUCTION I.I-(No septic system permitted if public sewer is <br /> `' available within 200 feet.) <br /> Installation will.serve: 1 Residence's�,Commerciail_ 1 Other <br /> F Number of living units: - Number oedroogls Dfi <br /> [ C <br /> Character of soil to a depth of 3 feet: -► d Water table depth <br /> r SEPTIC TANK ❑ T e/Mf t?vl e t �/ <br /> YP 9 Capacity—& _ No. Compartments 2 <br /> PKG. TREATMENT PLT. ❑ ._.. t- Method of Disposal Z_ey <br /> Distance to rteaiest: WellFoundations Property Line glin <br /> rr. \ LEACHING LINE UN.. & L"ength of lines v2 +. F't fil__ Totalleg/s e <br /> FILTER BED ❑ Distance to nearest: �- .Well©"e�Foundation_2Lg0 —Property Line dd <br /> P <br /> SEEPAGE PITS I 1 Depth Size ` Number <br /> j SUMPS LY Distance to nearest: Well Foundation 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 Diltrict. <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t all fora requ' d pections. Complete drawing on r rse side. <br /> Signed X Title: Date: <br /> ,sd <br /> DE ONLY, <br /> pplica io ccepted y Date Area 1 �� <br /> n p 9 <br /> or rout ns n W( Date `� .' —� / Final Inspection by 1 Date <br /> a Additional Comments: F <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-.4823-7104 ❑ 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 /> r <br /> FEE <br /> k � i <br /> I K ti <br /> INFO AMOUNT DUE AM NT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> 1 "I �j <br /> 1 - �{ EH 14-2e iREV.I/H51 J�/ -01-0-0 <br /> L.(0 <br /> EH 13-24 � /; <br /> v (f (� <br />