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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I 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. <br /> l <br /> Job Address Z City Lot Size PM� Q'+�,-�— , <br /> Owner's Name Address // Phone - - <br /> "- Address 1�� �a1License No. Phoned <br /> Contractor ! <br /> TYPE OF WELL/PUMP:""' NEW WELL ❑ WELL REPLACEMENT."❑,." << DESTRUCTION ❑y, ` ' <br /> _..-PUMP INSTALLATION,❑... _ = .__,-SYSTEM REPAIR :L] OTHER❑ w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION^'°" °"' °'"" "'°"AGRICULTURE WELL <br /> ) OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F" <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private _-D "Gravel Pack ❑ Tracy Type of Casing Specifications [ <br /> ❑ Public [IOther LDDelta Depth of Grout Seal Type of Grout <br /> w ElIrrigation _-Approx. Depth " EI Eastern Surface Seal Installed by <br /> I Repair Work Done . LJ Type of Pump H.P. ¢" State Work'Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION PIDESTRUCTION 71 (No septic system permitted if public sewer is <br /> T available within 200_ feet.) } � <br /> Installation will serve: Residence 4�Commercial Other <br /> M <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK i ❑ Type/Mfgt�g� Capacity /inn No. Compartments <br /> iPKG. TREATMENT PLT:F] Method of Disposal,' <br /> Distance to nearest: Well J r Foundation - Property Line " <br /> LEACHING LINE f"No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well' ,J 'iO�'_- Foundation 4/0 Property Line 4:: <br /> 77 <br /> SEEPAGE PITS -L�?--.I Depth e��_,-... -Size l -3 e� h Number <br /> SUMPS ❑ Distan a to nearest: Well I��f Foundation -66 4" Property Line <br /> DISPOSAL PONDS ❑ <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 District. i i. <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 rformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> 'tion laws of Califor I ..w <br /> I jThe'pr <br /> ust for al equir spections. Complete drawing on reverse do a?, <br /> Si ned �t Title: Date: x <br /> 9 _ , <br /> FOR DEPARTMENT USE ONLY , <br /> 1 <br /> Application Accepted"by Date" -I y Area d !3 r <br /> Pit or Grout Inspection by -ateFinal Inspection by ����nu a d.4 Date <br /> Addi#iodComments:-„,'�"""'"'""`”' � <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.Q. Box 2009, Stk., CA,95201. <br /> AMOUNT DUE AMOUNT REMITTED_ CK# RECEIVED BY DATE. z ` PERMIT`NO. <br /> FEE CASH <br /> - INFO <br /> ' + EH 13-24(REV.)/0 5fL' <br /> EH 1428 f �3• a � �` � �1 � <br />