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APPLICATION FOR PERMIT } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZELTON AVE., STOCKTON, CA � <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <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 j <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. 9 l <br /> Job Address _` d-" 21j049� City Lot Size&U G"Pfir,M <br /> Owner's Name /T At// Address "...\Phone <br /> Contractor's Name � � License No. - Phone S <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT'❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO'NEAREST:'SEPTIC TANK EWER"LINES . . DISPOSAL FLD. PROP. LINE S t <br /> t FOUNDATION # AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> , I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { <br /> ❑ Industrial l &-OW Bottom sj`❑ Manteca Dial of Well Excavation Dia. of Well Casing II <br /> &'Qdm�stic/Private i ❑ Gravel Pack ❑ Tracy Type of Casing Specifications L [ l <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type o r t., <br /> ❑ Irrigation ��4p0r x'Depth" ❑ Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Puinp H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.! I <br /> finstallation will serve. Reside6ce_ Commercial-__.- Other <br /> a <br /> ' 'Number of living units: Number of bedrooms <br /> J <br /> Character of soil to a depth,of 3 feet: Water table depth <br /> SEPTIC TANK .❑ ,7ype/Mfg Capacity No. Compartments <br /> PKG.-TREATMENT PLT. ❑ ' f Method of Disposal * <br /> 'Distance to nearest: Well Foundation Property,Line i <br /> LEACHING LINE. .�'t :'No. & Length of lines Total length/size ; <br /> FILTER BED ❑J." Distance to nearest: Well Foundation Property Line <br /> i 1 <br /> SEEPAGE PITS ❑ `Depth Siie Number <br /> SUMPS '❑\Distance to nearest: Well Foundation Property Line <br /> DISPOSAL POND'S ""T] <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� f-the San Joaquin Local Health District. H <br /> Home owner..ar 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 anyperscjn in;such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature' <br /> certifies the,following:."'I certify that in the performance of the work-fovwhich this.permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." I.,r <br /> The applicant must call for all required inspections. Co late drawing on reverse 'Side. %, <br /> Signed Title: _ Date: <br /> f FOR DEPARTMENT USE ONLY i <br /> t r <br /> Application Accepted by Date � Area <br /> Pit or Grout Inspection by .,Date Final Inspection b Date <br /> QY 6re� k w r,v u✓ It^ of f/ lu J7cw.e 4�1'erb, - Y4v j— <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835-6385 j " l rcc I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601,:.E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 11 ��`�✓C(J <br /> INFO AMOUNT DUE AMOUNT REMITTED LL'r CASH* RECEIVED IRY <br /> _ DATE PERMIT'NO. <br /> + <br /> EH - <br /> 133-z2a IRev,io/eal •-70 <br />