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T <br /> y <br /> z <br /> `- ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE„ STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 7 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 j <br /> Local Health District. <br /> /�Cif Ls <br /> Job Address City —Lot Size ply4 <br /> a <br /> Owner's Name Address Phone <br /> (f14_y <br /> Contractor Address License No.41Z Phone / l <br /> TYPE OF WELL/PUMP: W WEL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� DISPOSAL FLD. '"� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL r OTHER WELL �'�� PINS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM1AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ET Open Bottom ❑ Manteca[I Dia. of Well Excavation Dia.lof Well Casing <br /> 14 <br /> omestic/Private ❑ Gravel Pack ❑ Tracy �Type <br /> of Casing Spg cificatio <br /> FI 1 Public ❑ Other n Delta VDoth,of Grout Seal Meg T' e oerGti <br /> fout <br /> I i Irrigation -�C99�Approx. Depth I I Eastern Surface/.Seal Installed by �. <br /> Repair Work Done LJ Type of Pump H.P._-3V __ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> ---.Depth-.Depth.._:____._... __.Filler•_Marerial.lBetgw <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( IREPAI_RIADDITfON (.I DESTRUCTION I I INo septic system permitted if public sewer is <br /> I ti f �,� "` •�- _--=�—.- �. available within 200 feet.) <br /> installation will;serveResidence_ Commercial Other <br /> Number of living units: Number of bedrooms ry U <br /> Character of soil to a depth of 3 feet:_ifrx r -- — -- table...` Water ble depth I <br /> SEPTIC 1fANK ❑�Type/Mfg �f Capacity No. Compja`Aments <br /> PKG. TREATMENT PLT. ❑ % Method oeDisposaf <br /> }/Distance to nearest:P_M iWe#--- ----------Foundation Property Line <br /> LEACHING LINE Cl No. &.Lo gth of IinL ` n.l i Total length/size I y r 1 <br /> r14 J i <br /> FILTER BED i ❑ �Distatice to nearest) Well Foundltion Property Line�..__�` <br /> SEEPAGE PITS `� —-I�l 'Depth " Size <br /> ..._:.... ..._ Number <br /> SUMPS ` �� L] Distance to nearest: Well F� Foundation Property Line i i� <br /> DISPOSAL PONDS ❑ <br /> I herehy.lCrr6uli_) hit hhave'prepare'd-tKis appficatio-n�an 'ythat;lie work wilf-tie done in accordance with San Jo'aquin+cbuAty ordinances, state laws, and <br /> rules an regulations of the San Joaquin Local Health bijrict. <br /> Home owner or licensed agent's signature certifies the fyllowing: "I certify that in the performance of the work'for which his 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 hiri g or sub-contracting signature <br /> certifies the following: "f 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." ,.,, .,. ,,,.,1---- ___ __ - <br /> The applican u I requ' r ns: Complete drawing on reverse side. <br /> Signed X itle: *� D ate: 4 <br /> X45 jl F6A4DEPARTMENT USE ONLY !� <br /> Application Accepted b1by �45. r Date 'P �{ -1 ^ <br /> rea <br /> \ l <br /> Pit or ro Inspection Date Final Inspection by ' DateAdditional Comments: j# / <br /> ❑ Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <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 CK RECEIVED By DATE PERMI7'NO. <br /> INFO �. 1 ASH <br /> ..EH 13-241R€V.t/nsl ( „ f <br /> EH 14-28 <br /> f i ' <br />