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APPLICATION FOR PERMIT 'S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.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 compliake 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 OistriN, <br /> �( Lf , � City ' Lot Size PM — <br /> Job Address1 1 /� <br /> J AddressS-��-�` '6 , Phone "I <br /> 0wrier's Name r,� <br /> Address L'�' L.icense No��23�� Phonts7-� <br /> Contractor i v WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ . OTHER ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER;LINES <br /> DISPOSAL FLD. PROP. LINE <br /> 11. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial <br /> ❑ Open Bottom L1Manteca Dia. of Well Excavation `""-" , Dia- of Well Casing <br /> "� <br /> C3'DomestiGPrivate Grave! Pack ❑ Type of Casing Tracy _ ` l Specifications r f <br /> --) Type of Grout <br /> 1-1 Public Other n Delta Depth of Grout Seal <br /> Cl A <br /> 11 Irrigation .-Approx. Dept t I Eastern Surface Seal Installed b Y <br /> H p -- I State Work;Done. <br /> Repair Work Done 2 Type of Pump <br /> Sea Material {fop 5t)`} <br /> Weft Destruction ❑ Well Diameter g t µ <br /> Depth j Filler Material IBelow 5(p <br /> o seTYPE OF SEPTIC WORK: }NEW INSTALLATION 11 P,LPAIR/ADDITION I 1 DESTRUCTION I I aNailabpe'w thine200 feepermt�)ed if pit ublic sewer is <br /> a.. r_. <br /> -Installation will serve: Residence Commercial Other 1 <br /> Number of living units: I Number of bedrooms ! <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> I�" `.ti F CapaLity No. Compartments n <br /> SEPTIC TANK �I ,TYPe/Mfg .�� - �. .w _ NJ f. <br /> f PKG. TREATMENT PLT. ❑; Method at Disposal <br /> 1 Distance to nearest: Well Foundation Property Line q <br /> r j <br /> ! ' Total length/size <br /> k LEACHING LINE /0 'No. & Length of lines Yr. l <br /> F FILTER BED {7 Distance to nearest: Weif Foundation Property Line <br /> I <br /> ( SEEPAGE PITS l 1 Depth Site-- F Number <br /> 1+ff <br /> x SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> E3r <br /> DISPOSAL PONDS t lr <br /> hereby certify that I have prepared this application and that the work will be donelin accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari Joaquin Local Health Di"Wict. <br /> I Home owner or licensed agen['s'signature certifies the following: "I certify that in theoperformance 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 <br /> the performance ofithe work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California:" <br /> The applicant st cal for ail requI h d inspection . Com6lete drawing on reverse side. <br /> 1 Signed X_ I Title: <br /> Date; <br /> F f. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> r(Y� — Date <br /> Pit or Grout Inspection by Date Final Inspection by B,� <br /> 4 <br /> I Additional Comments: <br /> ❑ Stk 466-6781 1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> )NFO AMOl1NT DUE AMOUNT REMITTED CASH [ — <br /> ♦.EH 13-241REV.lin51 <br /> - Gdt P-1-7Fy �r-2Zz� <br /> EH 14-26 <br />