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APPLICATION FOR PERMIT <br /> SAN JOAQUINLOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t, <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. 18M for well/ <br /> pum <br /> Local Health D1 strict.' and the Rules and Regulations of the San Joaquin .. <br /> Job Addressi /lam r��/idGj r <br /> City ' :Lot Si �/� ` <br /> � PM <br /> Owner's Na-n ll-a � i�'R' Address'; /!(✓ C <br /> Phone <br /> Contractor - •' <br /> Address License No.- ' Phone <br /> TTPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ . OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL `.OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal t [� <br /> ❑ Irrigation Type of Grout y <br /> 9 —_Approx. Depth ❑ Eastern Surface Seal Installed by �'' <br /> Repair Work Done ❑ Type of Pump WP, ' - J <br /> State Work Done J <br /> Well Destruction ❑ Well Diameter Sealing Material hop 50'j" <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sew9er is <br /> 'i, available within 200 feet.1 <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: ! 9 <br /> Water table depth 5� <br /> SEPTIC TANK X"T Mfg Cepacity_� �a No. Compartments <br /> PKG. TREATMENT PLT. ❑ � } Method of Disposal <br /> 1� <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ><'-No. & Length of lines dotal length/size Be> <br /> FILTER BED 1-1Distance to nearest: Well ._ <br /> F dation,�D'fJ— Property Line � "t <br /> r <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Pro <br /> DISPOSAL PONDS ❑ Perry Line <br /> I hereby certify that I have prepared this application and that the work will tie 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 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,I shall <br /> tion laws of California." em pto <br /> Y Persons subject to workman's compensa- <br /> The applicant rpVst call fpr all required ' spections. Complete drawing an reverse side. <br /> Signs CL 14UI22-��Title: Date:OAO" ­— . - . I -- r <br /> / <br /> OR DEPARTMENT USE ONLY i <br /> Application Accepted byDate ~ A-1 -7 <br /> Area <br /> Pit or Grout Inspection by Dater <br /> Final Inspection by <br /> Additional Comments: _ <br /> 11Stk 466-6781 EJLodi 369-3621 11Manteca 823-7104 ❑Tracy 835-6385 _ µ <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 SH PERM <br /> INFO 17'NO. <br /> �} I! <br /> 4+ EH 14-28 <br /> 4-24IREv.1/0 5) <br /> 14 <br /> EH -Ze <br /> r i r 1 i <br />