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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT p <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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. 1lw <br /> r,� # y 1�-10U40t Size PM <br /> Job Address _ �`-' —O�"v\l5 City + <br /> Owners Name <br /> J��W\�3.. VAddress \C U. Phone ��' CO <br /> ' <br /> ��� C <br /> C T Address o�1 License No. Phone 3-_ �c3 <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT 171 .. ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ A{� <br /> DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP5�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casig <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation <br /> T of Casin Spec'if'ication <br /> ❑ Domestic/Private Ll Gravel Pack ❑ Tracy Ype g T e of Grout <br /> El Public ❑ Other L3 Delta Depth of Grout Seal YP <br /> ` ❑ Irrigation Approz: Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Hone ❑ TYpe <br /> of Pump I H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') # <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO `(No sbptiwi hnam rented if public sewer is <br /> Installation will serve: Residence -1Commercial_ Other �: { <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 3 <br /> } " Watei table depth <br /> s' _ <br /> Capacity i No. Compartments <br /> SEPTIC TANK Ll .Type/Mfg' <br /> PKG. TREATMENT PLT. ❑ "I Method of Disposal <br /> "Distance to nearest:.'- Well Foundation a Property Line <br /> LEACHING.LINE El No. & Length,of lines `. <br /> / Total length/size <br /> FILTER SED ❑ "Distance to nearest: Well % Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size �s Number <br /> ' -'-. T Property Line <br /> SUMPS IJ Distance to neatest'.`. Well Foundation <br /> DISPOSAL PONDS ❑ r S <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 <br /> rules and regulations of the San Joaquin Local.Health.District. <br /> Home owner or licensed agent's signature certifies;tFre following: "I certify that in tfie performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman s compensation laws of CarrfI shalt <br /> t Contractor's hiring : sub-contracting signature <br /> certifies the following:"1 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 /> ction <br /> The applicant must call for all r pes. Complete drawing on revs ide. t <br /> ,� <br /> Title: Date: <br /> Signed _ y <br /> FOR DEPARTMENT^U5E ONL ` <br /> � ` r <br /> 'f 1, Date I I 4 G Area <br /> Application Accepted by ," f� Data r <br /> Pit or Grout Inspection Date <br /> Finale Inspection by <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca ffi3 7104 El Tracy 83-6385 <br /> 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services <br /> !�CK PER <br /> FEE AMOUNT DUE AMOUNT REMITTED IRECEEIVED DATEiliMIT4+ EH13-24MEV.tiie5Y `1!6,6%9V J.0 0 ® " 1hZ <br /> 0 <br /> EH 14-28 <br />