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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. <br /> Job Address � > <br /> City 4k� Lot Size PM <br /> Owner's Name Address � "'��^Mf <br /> Phone <br /> Contractor's Name _ License No. Ph <br /> one <br /> TYPE OF WELL/PLUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ —SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t R1 <br /> ❑ Industrial C1 Open Bottom <br /> p k w,F❑ Manteca I Dia, of Well Excavation Dia. of Well Casing t <br /> ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Specifications 1 <br /> ❑ Public El Other + D pelta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �pprox._Depth n ❑"Eastern Surface Seal Installed by f' t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealirig Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION)( REPAIR/AD`DITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is <br /> i ,- available within 200 feet.! <br /> Installation will serve: Residence)g� Commercial I Other <br /> Number of living units: Number of bedrooms + <br /> Character of soil to a depth of 3 feet: . Water table depth- �' r• <br /> SEPTIC TANK ❑ Type/Mfg Capacity !2d© No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well_2,.�+ar `tc undation Property Line <br /> LEACHING LINE X No. & Length of Gn TataJdength/size-- ,d. <br /> FILTER BED ❑ Distance to nearest: Well. � <br /> Foundation ?o Property_Line«_ ; .5 • <br /> SEEPAGE PITS Depth .s Size Number <br /> SUMPS ❑ Distance to nearest: Well /00 Foundation AQ/ Property,Li e„ ' S <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 ordinance , state laws, and <br /> rules and regulations of the San Joaquin Local Health District. _.,," `-k,\\ `-�Z�- - <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."Contractoes•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." , <br /> The applic m st for all r it inspe tions. Complete drawing on reverse side. • t ; <br /> Signed Title: _ Date7Y : <br /> FOR DEPARTMENT USE ONLY > <br /> Application Accepted by Date �IRK Areaall <br /> Pit or Grout Inspection by Date� Final lnspedtion by oAIV .Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 VLodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copr to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O: 86x 2009,7'Stk., CA 95201 <br /> FEE w INFO~ MOUNT DUE AMOUNT REMITTED CASCK*H m RECEIVED BY— ---DATE —PERMIT'NO. -' <br /> + EH 13.24 4REV, 10/83) ��IJ a 0� <br /> EH 14-28 <br />