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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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. <br /> Jab Address ®lam L 01L City L Lot Size PM <br /> i <br /> t Owner's Name L r Address 1 V d � Phone <br /> A <br /> E Contractai \N_ kL:'}AY\1_ti_ ALC` -ddress License No. Phone <br /> f TYPE O.F_.WELL/PUMP: ,, NEW.,WELL ❑._,._ ­WELL REPLACEMENT, <br /> ❑. DESTRUCTION ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ V <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 /> FI Public f1 Other 11 Delta Depth of Grout Sea! Type of Grout 1 <br /> I I Irrigation _Approx. Depth { I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') r + <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION W­EPAIR/ADDITION 171 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> { �h <br /> Installation will serve: Residence_ Commercial*– er <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: i. s - Water table depth <br /> SEPTIC TANK L91T9pe/Mfg apacit� No. Compartments <br /> PKG. TREATMENT PLT. O t i. s Method of Disposal <br /> Distance to nearest: Well __ .. Foundation 14S. V Property Line 17�Q <br /> LEACHING LINE &—fto. & Length of lines f Total length/size <br /> FILTER BED Cly; Distance to nearest: Well a"" Foundation ZID Property Line <br /> SEEPAGE PITS 1 1: Depth Size Number <br /> SUMPS LI: Distance to nearest: Weil 'Foundation r Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatiori'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 the following: "I certify shat 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 performarice of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> n laws of California." a f <br /> The app i mus c II all re uire ns late drawing on r verse side. •_ __ -. _ r <br /> } <br /> Signe Title: Hate <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byL3'Vv <br /> -Date'--1217An Areas <br /> Pit or Grout Inspection by _ Date Final Inspection by Date <br /> Additional Comments: &w" <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601,E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE i <br /> r INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p PERMIT'NO- <br /> + EH 13.24(REV.I/H 5) 1 Q ?j 91fl <br /> EH 14-26 ! Ll <br /> A <br /> _l <br />