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APPLICATION FOR PERMIT ^� it <br /> SAN JOAQUIN LOCAL HEALIITH DISTRICTS <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ` s <br /> Telephohe (209) 466-6781 <br /> r <br /> &r,,le PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 0 E ' C' 19-89 <br /> (Complete in Triplicate) -� -�� ;;�;3,t1I I <br /> vsr <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desc`ribetl'IThlsappllc tion 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 . 25J� "rCv c- I;- i L)eA- City 57!fG ot siZe PM <br /> Owner's Namel Address <br /> Phone <br /> IM. <br /> 1�Contractor CL [) �/°! e- <br /> on License No Phone ��� o� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION IT <br /> I�. PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 7 FOUNDATION AGRICULTURE WELL' OTHER WELL PITS/SUMPS <br /> INTENDED,USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial "I! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> YDomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public n Other ❑ Delta, r Depth of Grout Seal Type of Grout <br /> I I Irrigation <br /> --Approx. Depth { Eastern Sur ce Seal Installed by <br /> Repair Work Done Type of Pump _ H.P. <br /> s State Work Done � ��- <br /> Well Destruction ©-4"WeII Diameter Sealing Material (tap 50') <br /> a, <br /> Ip' r Depth_ 'Fillet Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> a ! + available within 200 feet.) <br /> s" Installation will serve: Residence,— Commercial--Other <br /> Number of living units,—_ Number of bedrooms <br /> Character of'soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK; IDType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> i Method of Disposal <br /> Distance to nearest: Well Foundation' <br /> w Property Line <br /> ,I. <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ "Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS' I i Depth Size <br /> Number <br /> SUMPS "❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS F1 . <br /> (hereby certify that I have prepared this application and that the work will,be-dono-in'accordance with San Joaquin county ordinances, state laws, and <br /> rules and regul(tions of the San Joaquin Local Health Diktrict. <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 peiion in such manner as to become subject to workman's compensation laws of Cajifornia."Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compens <br /> tion laws of California." a- <br /> The applic all for all required insp tions. plate drawing on reverse side. <br /> Signed X �� - " . �� / <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by C <br /> Date � Area <br /> 1� -- <br /> Pit or Grout Inspection: by Date Final Inspection by Date 4 . <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621• ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-0. Box 2009, Stk., CA 95201 <br /> INFOFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y i <br /> (� CASH DATE PERMIT"NO. <br /> `L $ <br /> +.pH 13-24(REV. <br /> EH 14-26 <br />