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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZEIt`ON AVE., STOCKTON, CA <br /> Telephone {200} 466-6781 u <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> uin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaqty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Coun <br /> Local Health District. q <br /> r <br /> ♦� City+� Lot Size PM <br /> Job Address �' f <br /> Address Phone <br /> Owner's Name <br /> License No, <br /> Contractor <br /> A 4 - L.-CYl a Address -! �P_,e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER Cl <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE' j: TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> EJ Domestic/Private m❑ Gravel Pac� ❑ Tracy Type of Grout — <br /> ui D Delta Depth of Grout Seal <br /> l'l Public Cl Other � _ <br /> 1 . <br /> I I Irrigation --Approx. pepth I I Eastern Surface Seal Installed by 1 <br /> r Repair Work Done ❑ Type of Pump <br /> I H P State Work Done'— <br /> I Sealing Material atop 50'1 <br /> Well Destructiohs ❑ Well,Diameter <br /> Depth Filler Material IBelow 501 <br /> TYPE QF SEPTIC-WORK: NFW INSTALLATION t'l REPAIR/ADDITIQN DESTRUCJTION l 1 availablec system within200 fe tlt�ed if public sewer is <br /> Installation will serve: Residence_ Commercial Other ! 5lA <br /> Number of living units: Number of bedrooms - Water table`depth <br /> Character of soil to a depth of 3 feet:' ' <br /> Capacity l No.°Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ <br /> r <br /> `p Method of Dispos� <br /> Property Line <br /> Distance to nearest: Well_. Foundation�. P Y <br /> LEACHING LINE 1 No. & Length o1 lines <br /> --- / 7, Total,lengthl size <br /> ❑ Distance to nearest: Well f� Foundation �Property Line <br /> FILTER BED 1 _ <br /> c <br /> SEEPAGE PITS I 1 Depth Size - <br /> Number �w <br /> SUMPS ❑ Distance-to-nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS ❑ <br /> r 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 Di§trict. ,,. <br /> Home owner.or licensed agent's signature certifies the following: "I certify that``the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as signature <br /> to become subject to workman's compensation laws of California." Contractor's Kiring <br /> b ect to workmantrsor compensa . <br /> certifies the following: "I certify that in,the-performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." r ` <br /> The applicant must call for regwrod specti . Complete drawing on reverse <br /> Date: ! (o•' � <br /> Signed X c Title: —� „ <br /> r F R QEPARTMENT USE ONLY <br /> J. Date Area <br /> Application Accepted by <br /> ` Date Final Inspection by Date <br /> Pit or Grout Inspection by - , <br /> i Additional Comments: <br /> ❑ 5tk 466 67814 ❑ Lodi 369-3621 C1 Manteca 823-7144 13 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 /> - CK RECEIVED BY--- - DATE a'N0. A <br /> T R <br /> FEE ..AMOUNT-DUE AMOUNT-REMITTED CASH <br /> " INFO <br /> +.EH 13-24 jNEV.111151 �70 <br /> EH 14-28 <br />