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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 456-6781 <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District.`a Job AddressJ5L-.[ f Cit K l ` _ Lot Size M <br />Owner's Name Address��`} �` f Phone <br />Contract 2G <br />TYPE OF WELL/PUMP: <br />DISTANCE TO NEAREST <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />1°l Public <br />I I Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />Address 1__= <br />2 0 Phone <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION _ ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL <br />❑ Open Bottom <br />❑ Gravel Pack <br />[-1 Other <br />— Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA <br />❑ Manteca <br />❑ Tracy <br />R Delta <br />I 1 Eastern <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation <br />Type of Casing <br />Depth of Grout Seal <br />'Surface Seal Installed by <br />H.P. State Work Done <br />Sealing,Material Itop 501 <br />er Material IBelow 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR ADDITION K DESTRUCTION I ] INo septic system permitted if public sewer is <br />/ available within 200 feet.I <br />Installation will serve. Residence r Commercial _ Other <br />Number of living units: J_ Numbeaofb oomsCharacter of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANKIMF <br />Type/Mfg T Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE No. & Length of lines Total length/size_ r <br />FILTER BED ❑ Distance to nearest: Well`S�-- Foundation Property Line <br />SEEPAGE PITS t I Depth Size Number <br />SUMPS Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ _--_ <br />Dia. of Well Casing <br />Specifications <br />Type of Grout _ <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 Di§trict. <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, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applicant t call far req d inspections- Complete drawing on reversje id� Q <br />i Title: �/` 1 ' Data` 4 <br />Signed X """' - k <br />0 FDR DEPA�'MTT US,� O7 L1`-�. <br />Application Accepted by Date Area <br />1 <br />Pit or Grout Inspection by D:... _Final Inspection by � �� Ra f <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.O. Box 2009, Stk., CA 95201 <br />+.EH 13-241REV. I/ AS) <br />EH 14-2e <br />FEE <br />1NrO <br />AMOUNT DUE <br />AMOUNT REMITTED CK <br />CASK <br />RECEIVED BY <br />DATE <br />f ERMIT'NO. <br />'C-1 0 , Co <br />1 (:)r -L4--&6-, <br />