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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON 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. v — a <br /> Cit _�� -- Lot Size <br /> Job Address !�"1 00 <br /> • .�. Owner's Name <br /> �U!!!/ Address —/s~� - � T } Phone <br /> h t rCJ Address /� License <br /> Contractor Noc�•5` 11 <br /> �_Phone <br /> KAV <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTR 07°R ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. ONE <br /> NE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> LI Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout <br /> [-] Public ❑ Other ❑ Delta Depth of Grout Seal <br /> I I irrigation __,.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done 0 Type of Pump <br /> H.P. <br /> Well Destruction ❑ Weil Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 50 1' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I iNoavaseptic <br /> system <br /> ithin m permit" <br /> d public sewer is <br /> ' Installation`will serve: Residence,commercial Other <br /> Number of living units: --$-2% Numbt!a <br /> Water table depth <br /> Character of soil to a depth of 3 feet: t <br /> SEPTIC TANK � type/Mfg I' f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of c/Disposal <br /> Distance to nearest: Well Foundation/C1f Property Line q <br /> �fa Total length/size <br /> LEACHING LINE r No. & Length of lines A <br /> y-- <br /> FILTER BED Ll ,Distance to nearest: Well Foundation property Line <br /> SEEPAGE PITS I I Depth L=T- Size Number T <br /> SUMPS L Distance to nearest: Well Foundation Property Line r 11 <br /> f <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 ordinances, state laws, and r <br /> L rules and regulations of the San Joaquin Local Health Oiltrict. <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." Contractor's hiring or sub-contracting signature <br /> +: crtifies 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 applicant must call for require inspec 'ons. Complete drawing on re a side. l�✓� ' <br /> Signed X f Title; Date: d <br /> FO PART NT USE ONLY �1 <br /> Ar <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> 5 Additidnal Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104, ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health. Pefmit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> ffFECCK ASH RECEIVED BY DATE PERMIT NO. <br /> aAMOUNTEDUE <br /> AMOUNT REMITTEDEH t3-2b IREV.t/x 51 5b—o <br /> EH 14-2e <br />