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r , <br /> I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. AZ <br /> Lot Size PM <br /> Job Address -�r City ;> <br /> Owner's Name ► 7 r ��� 44�rTress c �X Phone <br /> - - <br /> r Address # License-No. Phone <br /> Contractor `� <br /> 4. TYPE OF WELL/PUMP: 4 NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ N <br /> PUMP INSTALLATION ❑ --SYSTEM <br /> SYSTEM REPAIR ❑ OTHER ❑ g <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private EJGravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other 11 ❑ Delta- Depth of Grout Seal Type sof Grout <br /> ❑ Irrigation ---4pprox 'Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ElType of Pump H.P. State Work Done <br /> Well Destruction F] Well Diameter Sealing Material.{top 501 <br /> Depth ,I _filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nosepti cysthin m emitted if public sewer is <br /> availabr <br /> Installation will serve: Residence� Commercial_ Other , <br /> Number of living units: Number of bedroo i <br /> Character of soil to a depth of 3 feet`:( Water table depth <br /> SEPTIC TANK 1:1Type/Mfg! apacity� /D M4 10tiNo. Cornpartments <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance.to nearest: Wja Foundation - Property Line -�Q= <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> ^� Q <br /> 4 FILTER BED ❑ Distance to nearest: We Foundation ev o1 Property Line S c <br /> i <br /> Number <br /> SEEPAGE PITS ED Depth Size 3- <br />` SUMPS O Distance to nearest: Well 'Foundation� Proparty Line .— <br /> DISPOSAL PONDS ❑€ i <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 /> k rules and regulations of the San Joaquin Local Health District. <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, 1 shall not <br /> I employ any person 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 for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." t# <br /> The applicant must call for all required inspections. Compldrawing on reverse <br /> rse side. <br /> ete <br /> Signed Title: 'Date: ', I �"F-7 <br /> g R, t t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date = Area <br /> Date Final Inspection by fts Date �C.�es:r r, �l� <br /> Pit or Grout Inspection by F (/ 0 I <br /> Additional Comments: <br /> r Ll 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.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED• CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO �7 L/ <br /> + EH 13-24(REV.1/65l <br /> I ( 7,.:�.� . <br /> EH 14.28 f/ <br />