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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZES i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> fi R (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.TNs 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. 9, <br /> - r <br /> Job Address Z City Lot Size �'�' PM <br /> Owner's Name dress Phone <br /> Contractor Address License,No. Phone ! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ° SEWER LINES , ^ . DISPOSAL FLD:- --- PROP..LINE 4 <br /> FOUNDATION" AGRICULTUREiWELL OT, <br /> INTENDED <br /> -tl ; �.PITSI,SUMPS <br /> INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial-- %� ❑ Open Bottom _ _❑ Manteca Dia': of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Graavel Pack C1'Tracy': rType of Casing Specifications w ' <br /> ❑ Public =` 0 Other ❑.Delta t CDepth of Grout Seal Type of Grout <br /> ❑ Irrigations—:--4pprox. Depth ❑ Eastern Surface Seal Installed:by <br /> sr. ^ n <br /> Repair Work Done ❑ Type of Pump H.P. � State Work Done `7`J <br /> Well Destruction ❑. Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Bel w 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION d REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is T\ <br /> .4 € available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other_ <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:1", v r Water table depth <br /> SEPTIC TANK ,. ❑ Type/M64 J. Capacity AS-0 O No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 > l /N Method of Disposal <br /> Distance to nearest: Well Lod Foundation l� 'T Property Line s— <br /> LEACHING LINE No. & Length of lines TotaYength/size <br /> FILTER BED ❑ Distance'to' nearest: Well Foundation�Q�roperty Line C <br /> �J f <br /> SEEPAGE PITS ❑ Depth r Size - /Number i <br /> SUMPS Distance to nearest: Well AW Foundation/LJ� Property Line —{ C <br /> DISPOSAL PONDS Q <br /> I hereby certify that I have prepared this application and that the work will be done in accofdance with San Joaquin county ordinances, state laws, and <br /> 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, 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 /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." r p <br /> The applicant mus call for al re ed ins lo . Complete drawing on re rse side. <br /> fi <br /> Signed _ � �- - Title: � Date: ' <br /> FOR DEPA MENT USE ONLY, <br /> Application Accepted by Date Area <br /> Date Final In i� <br /> Pit or Grout Inspection by Inspection b Date <br /> A rtional Comments: <br /> AStk 466-6781 El Lodi 369-3621 Manteca 823-7104 El Tracy: 835-6385 <br /> pplicant-Return all copies to: Environmental IlleAlth 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 r <br /> + EH 13-24(REV,�ie 51 ��.�''� <br /> EH 14-26 _ i <br />