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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 0.5— /10 —`57 <br /> i <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 i <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for weil/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �c p. _1C . f r!�S Cl-fes- ' <br /> f Lot Size PM <br /> 'Job Address Y '# <br /> ' <br /> Owner's Nam <br /> dress ���/ Phone `. <br /> Contractor =N ' <br /> Q License iVo. PhoneWELL REPLACEME ❑ DESTRUCTION ❑TYPE OF WELL/PUMP: L <br /> PUMP 1NSTALLAT JON ❑ SYSTEM REPAIR ❑ OTHER❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD./52"— PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL --'PITS/SUMS <br /> I a <br /> INTENDED USE TYET OFIWELL PROBLEM AREA CORfCasing <br /> TION SPECIFICATIO <br /> ❑ Industrial <br /> Pan Bottom t� Manteca Dia. Excavation Dia. of Well Casing <br /> ' TypSpecifications)❑ Domestic/Private ❑ Gravel Pack ❑ Tracy /V <br /> (� Other Cl Delta Depth of Grout Seal Type at Gr ut . <br /> s rri anon --Appro k. Depth I i Eastern Surface Seal Installed by ._ <br /> i it Work Done ❑ Type of Pump H.P. State Work Done_ <br /> i Well Destruction ❑ Weli Diameter Sealing Material (top 50') <br />' <br /> Depth I Filler Material (Below 50') Wil" <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i l DESTRUCTION f I (No septic system permitted if public sewer is <br /> available within,Z00 feet.) � ti <br /> t <br /> t Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms >„ <br /> Character of%soil to a depth of 3 feet: Water table depth <br /> ' Capacity No. Compartments <br /> SEPTIC TANK . ❑ Type/Mfg, _ <br /> PKG. TREATMENT'PLT. ❑ <br /> (' Method of Disposal <br /> Distance to nearest: Well Foundation Property,Line -40 <br /> 3 Y{ <br /> Total length/size <br /> LEACHING LINE LINo. &&6gth.of_Iinesw = ,_, <br /> r . <br /> FILTER BED ❑ Distance to nearest: Well _-" Foundation Property Line I ' <br /> Number ; <br /> SEEPAGE PITS � 1 I.: Size Depth 4 <br /> SUMPS L�y Distance to nearest: Well Foundation Property Line <br /> �f.K {1 <br /> DISPOSAL PONDS ❑- <br /> I hereby certify that I have prei <br /> pared 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 /> I 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 sucti manrier`as to become subject to workman's compensation laws of California." Contractor'spiring of sub-contracting signature <br /> certifies the following: "I cacti that ih the performance of the work for which this permit is issued,:i shall employ persons subjects to workman's compensa- <br /> tion laws of California." � <br /> The applicant m a I for a req spec 'ons. Complete drawing on re se side. I <br /> ✓ v <br /> Signed X 4 Date: <br /> !tea F, EPARTMENT USE ONLY <br /> �' - Data Area <br /> Application Accepted by . <br /> .Date Fina! Inspect _ "r' <br /> Pit or Grout Inspection by .._ ., —T <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369 3621 'y❑ 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-95201-1+ <br /> FEE AMOUNT DUE AMOUNT,\REMITTED CASH RECEIVE BY DATE PERMIT'NO. <br /> INFO <br /> INN <br /> t.EH 13-20(REV.i/n 5] <br /> EH 1I-26 1 <br /> k <br />