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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 /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <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. j <br /> o9 3 00� JePA o;*v Gr, i <br /> Jab Address City Ty.* Lot Size fr a � PM i <br /> WA1 Ter -e"—' a <br /> Owner's Name '46 LNC/_LAY' Address - Vt. Phone i <br /> Contractor 01 AWIX If NOW Address �� B��c (! 0r, License No. �t, Phone k <br /> TYPE OF WELL/PUMP:.'-- NEW WELL ❑ WELL REPLACEMENTO DESTRUCTION Ll" <br /> S: <br /> t .��PUMP INSTALLATION ❑ ", SYSTEM REPAIR i]�4+ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP�$AL FLD. POOP. LINE { <br /> r 401_11\16AT6N AGRICULTURE WELL = OTHER WELL PITS/SUMPS <br /> INTENDED USE 'TYPI= OF WELL, PROBLEM AREA `.,CONSTRUCTION SPEGIFICATIONS ^ <br /> ❑ Industrial ❑ Open Bottom LJ Manteca - Dia. of Well Excavation Dia. of Well Casing -N <br /> D Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications l i <br /> e f-) Public 1-1 Other ❑ Delia Depth of Grout-Seal,r % ,Type of Grout <br /> I I Irrigation 4 --Approx. Depth 1 I,Eastern Surface Seal Installed'by *' _ <br /> Repair WorkDone ❑ Type of Pump "H.P. � � State.Work Done.2. <br /> Well Destruction ❑ Well Diameter 3' j§ealing Material (top 50') <br /> +, Depth Filler Material'(Below 50'), <br /> TYPE OF SEPTIC WORK;. NEW INSTALLATION (1 REPAIR/ADDITION .DESTRUCTtON I I (No septic syst&p'permitted if public sewer i <br /> availabl_e within.200 feet.) <br /> Installation will 'serve: Residence Commercial_ Other +'• .� �, <br /> Number of living units: Irl Number of bedrooms <br /> Character of soil to a depth of 3 feet: . /�rl�O t+ +�•. ` Water table depth /C >�X <br /> SEPTIC TANK J' .0 Type/Mfg's Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal} <br /> Distance to nearest: Well Foundation Property Line 's <br /> LEACHING LINE 10 No. & Length of lines jE — J00 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well /0� Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll 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 District. <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." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance o th'e work for which this permit is issued, I shall employ persons subject to workman's compensa ` <br /> tion laws of California.". <br /> ti 3 k <br /> The applicant must call for all required inspections. Cot"hplete drawing on reverse side. <br /> Signed Title: Date: If 0 Z 8I <br /> If F R DEPARTf1ME1VT USE ONLY / <br /> Application Accepted by :. Date Area <br /> Pit or Grout Inspection by Date Final Inspection by �'' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca BM-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E:Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> EFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 5DATiEEPER NO. <br /> AIV <br /> + EH 13-24 IREV.EH 14-26 <br />