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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTCEI <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 SEP I i 1960 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> P (Complete in Triplicate) PERMIT/SERVICES <br /> M 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. 544 for sewage or No. 1862 for well/,pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> f i � <br /> Job Address , <br /> City ' Lot Size PM <br /> FC'.---+n l7/ff2.r Address - Phone <br /> Owner's Name ��--- } <br /> d/1 . - It <br /> I <br /> Contractor Address License No. �� Phone_ "� _ <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F1 SYSTEM REPAIR 13 OTHER <br /> Y8 DISTANCE T0`NEAREST: SEPTIC-TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> 1 <br /> I FOUNDATION AGRICULTURE= WELL OTHER WELL 'I PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' <br /> �. ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing " Specifications <br /> l'I Public 141 Other n Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation _.-Approx. Depth l Eastern urface Seal Installed by - <br /> Repair Work Done Vk Type of Pump <br /> H,P. L; S ate ork Done <br /> ' Sealing Material (top 50'). _ ! ` <br /> Well Destruction ❑ .Well Diameter_-. ,.---- <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR7ADDITION ( I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:' <br /> �. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> w <br /> i SEEPAGE PITS i I Depth Size Number <br /> ' 7 SUMPS- E C-1 Distance to nearest: -WelhF'" Foundation Property l in"e <br /> t <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San'Jobquin 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 /> I tion laws of California." „• <br /> The applicant must -11 For all required inspections. Complete drawing on reverse side. <br /> L w Signed X ,i' ui�I.D Title: _&4 � Date: <br /> 'nk <br /> OR DEPARTMENT USE ONLY Q� <br /> Data Area w <br /> Application Accepted by - <br /> Pit or Grout Inspection by I Date `` Final Inspection by Dat��7�/t <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> 1 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FE6AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 1$-241REV.I/n51 ®^`� <br /> EH 14-26 <br />