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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 /> 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. x� <br /> PM <br /> 18: <br /> V�- � Lot Sie _ <br /> Job Address city <br /> C:Girti^01�, <br /> SID �4 <br /> Phone <br /> Owner's NameAddress <br /> A l - ! 0 V 0 PhoneD <br /> Contractor's Name �. ri License No. ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 ; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK �— SEWER LINES ! DISPOSAL FLD. a PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> w iNTENDED USE TYPE`OF WELL iPROBLEMAREA','"CONSTRUCTION-SPECIFICATIONS n x <br /> .: ❑.Manteca <br /> ❑ Industrial ❑ Open Bottom Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy s Type of Casing Specifications <br /> ❑ Public El Other El Delta <br /> 1 Depth of GroutWSeal �. <br /> Type of Grout r <br /> i <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> S� H,P, State Work,Done <br /> Repair Work Done `% Type of Pump j 4 <br /> Well Destruction ❑ Well Diameter (/ Sealing Material.1top 501 ; <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No sbotic withm permitted if public sewer is <br /> Installation will serve: Residence— Commercial; .Other y r <br /> Number of living units: Number of bedrooms t <br /> -,-.- — --.•- .�----..,-�..:V .-, 'Water table depth <br /> Character of soil to a depth of 3 feet: . <br /> ,SEPTIC TANK 17Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ rMethod of Disposal 3 _- <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r <br /> Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> A <br /> SEEPAGE PITS ❑ Depth <br /> Size -1 Number <br /> SUMPS LJ Distance to nearest:' Well Foundation Property.Line <br /> r <br /> DISPOSAL PONDS ❑ ' "` f' ` <br />' application and that the work will;be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that I have prepared this <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.ta 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 thispermitis.issued„I shalt employ persons subject to workman's campensa _ :, <br /> tion laws of California." i I <br /> The applica ust I for all a re inspections. Complete drawing on r.verse side. �/� <br /> ' Title: `�a�Jt Date: b <br /> Signed r <br /> z FOR DEPARTMENT USE ONLY <br /> VI , <br /> Application Accepted by . F - DateArea <br /> z �. <br /> Date Final Inspection by. Date <br /> Pit or Grout Inspection by <br /> Additional Comments: ' <br /> KStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ fracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE <br /> INFO PERMIY'NO. <br /> CASH ^ <br /> +EH 13-24(REV.101831 101 00`'�[, <br /> EH 14-28 <br />