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APPLICATION FOR PERMIT . <br />` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f 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."1t362 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> E� "? <br /> Job Addressli _ City Lot Size 1� 2[ ply <br /> Owner's Name !{ �i4 �e f <br /> '�I" <br /> f Address &W A Phone yQCo <br /> Contractor «&tf AddressL License No. 3 J Phone <br /> ;TYPE OF WELL/PUM : NEW WELL WELL REPLACEMENT ❑ DESTRUCTEON;❑ <br /> %^ <br /> PUMP INSTALLATIO ❑ SYSTEM REPAIR ❑ � OTHER p <br /> OISTANC€.TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.� PROP. LINE _ <br /> L FOUNDATION 35- AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. h "`'` :1t ate i Q g dr <br /> ❑ Industrial I[ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack- Ll Tracy Type of Casing Specifications _lQ�f <br /> Ul Public l 1 Other _171 Delta Depth of Grout Seal Q Type of Grout_-_ <br /> I f Irrigation _App i I Eastern Surface"Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. " ' State Work pone <br /> �4 .Well Destruction ❑ Well Diameter Sealing Mater"ial {top.501 <br /> Depth + Filler-Material"(Below"501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR/ADt7l I ION-1_I-_ DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other j <br /> Numder of living units:'—Number of bedrooms <br /> t - <br /> Character of soil to a depth of-3 feet: Water table depth <br /> SEPTIC TANKS ❑ Type/Mfg # r <br /> Capacity—i .R ""`Nor&Ripartm6nts <br /> PKG. TREATMENT PLT. ❑ t s <br /> is Method"of Disposal <br /> Distance to nearest: Well, Foundation Property Line " <br /> LEACHING LINE ❑ No. & Length of lines s.r <br /> I Total length/size r! <br /> FILTER BED II ED Distance to nearest: Well Foundation Property Line j <br /> 4A! I . f <br /> SEEPAGE PITS i'I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A <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 of the work for which this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws of Californi <br /> The applicant mu a I-regnrred tnspectio plate drawing on reverse side. <br /> Signed�C - <br /> - ""Title: - •Date:- <br /> - <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accgepted by Date�C? Wr— Area <br /> Pit or G� nslpection by� � D1G <br /> ataFinal Inspection by <br /> Date <br /> Additional Comments: f <br /> ❑"Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED-BY DATE PERMIT'NO. <br /> ♦ EH 13-24{HEV.1/w 51 II � .� �(] `�� Q� <br /> EH 14.26 , �, /U_/Jy ,olf <br />-� I� l V V LLL11! C+Cf <br />