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i APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRACT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES,TYEAR FROM DATE ISSUED <br /> I . (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. r. <br /> � r <br /> Job Address ! p 4C City Lot Size PM <br /> Phone <br /> Owner's Name Address <br /> I <br /> Contractor Address License No.�'SS"� -Phone g � <br /> r <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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WELL \ PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial 11Open Bottom 0Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Ddrnesticl Private ❑ Grairel Pack ❑ Tracy Type of Casing,. Specifications <br /> I1 Public ❑ Other'- ' '� Nrl Delta Depth of Grout Seal Type of Grout —. <br /> ! I Irrigation { ``�- -Approx''Depth I I Eastern Surface Seal Installedtiby!' - - <br /> Repai5ld Vork Done ❑ Type of Pump <br /> H,P. Sfate Work Done _ I <br /> Well Destruction O Well Diameter Sealing Material (top 501 <br /> i Depth Filler Material (Below 50'1' <br /> TYPE OF SEPTIC WORK: NEW INSTAL CATION (iEPAIR/ADDITION IJ. _DESTRUCTIONMI I_(No septic system permitted if public sewer is <br /> = available'wit'hin 200 feet.} i <br /> Installation will serves Residence� Commercial�T Other Y <br /> Number of living units: Number of 6edroorn', > l <br /> Character of soil to a'depth of',!feet:r _A • _- Water table depth i <br /> SEPTIC TANK El, TYP 9 <br /> e/Mf .Capacity No. Compartments i <br /> j i <br /> � <br /> PK& TREATMENT PLT. L1 �, y x ._ ,� . ,, . . ,, .,� . Method of Disposal <br /> J <br /> Distance,to nearest: Well 16tO! Foundation A0 Property Line <br /> } I <br /> LEACHING LINE "' t (''No~ Le of lines 7Total length/size <br /> 4 FILTER BFD `r` 4 ❑ Distance to nearest: Well Foundation, _ Property'Line'= <br /> SEEPAGE PITS , l I Depth,_ A)F"T Size f = Number_ <br /> SUMPS Dista�tce:to nearest:' "1M1fell �Foundatiori �rPraperty Line <br /> Y '.♦ ^^'�i E y E <br /> DISPOSAL PONDS ❑ At f <br /> I hereby certify that I have prepared this application'and that•fhe work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health DROct. ; <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 toworkman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: 11 certify ihat.in the performance-6f the work for which this permit is issued,i shall,employ persons subject to workman's compensa- <br /> tion laws of California."' r } Ar <br /> p t ^ <br /> The app I <br /> licant must call fffoor�all�.rreequir`eddinspections..Complate drawing an revefse•side.• , <br /> � <br /> Signed X .Title: CiL� r _- Date: <br /> ''•"•4 r" ' OF(t EtP.ARTMENT USE ONLY <br /> Application Accepted [ay Y• Date Area <br /> Pit or Grout Inspectionby �~eF °A Date' Final Inspection by Date <br /> { Additional Comments:S# <br /> ! ❑ Stk 466 6781 ❑ Lodi 369-3621: r--1❑.Manteca' 823-7104 ❑ Tracy 835-6385 <br /> i r <br /> Applicant Return all copies to: Environmanfal Health Permit/Seivices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �,.. icisAd <br /> FEE_. "AMOI•INT-bUE­—AMOUNT-REMITTED' _CASH RECEIVEDZY HEPERMIT=NO. 7- <br /> -" " <br /> INFO <br /> r.EH 13-241v.iinsl ~ <br /> EH 14-29 <br />