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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM MATE 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. '-;?f -4.4 <br /> & <br /> Job Address A city Loi'Siz.; y l f PM <br /> -VY6 <br /> Owner's Name Address 47_jer-a�_ Phone .5 <br /> AddresVZ7_1-- icense No. Phone Phone ""94189F5 <br /> Contractor JiAt= IV <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT El DESTRUCTION El <br /> PUMP INSTALLATION E SYSTEM REPAIR 0 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK f 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 /> n Industrial 0 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private E:1 Gravel Pack C1 Tracy Type of Casing Specifications <br /> T71 Public 0 Other i C1 Delta Depth of Grout Seal Type of Grout <br /> Ll Irrigation ___Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done' [it Type of Pump H,P. State Work Done <br /> Well Destruction L Well Diameter <br /> 0f Sealing Material (top 50'1 <br /> Depth I '.Irial <br /> Filier Mate" 113elow 50') Id,111A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [D REPAIR/ADDITION LJ <br /> ,�k.DESTRUCTION 111-(No%el5tic'system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Otffer------- <br /> Number of living units: — Numbefr1of bedrooms �A o <br /> I � 4 <br /> Character of soil to a depth of 3 feet:A Water table depth <br /> I <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C. Method-of-Disposal <br /> Distance to nearest: W611 FoLkidation Pr;pertyiL!n#e <br /> LEACHING LINE 11 No.'& Length of lines Total length/size <br /> FILTER BED C Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS D Depth. I -Size Number <br /> ' <br /> SUMPS EJ Distance to nearest- Well Foundation Property Line <br /> DISPOSAL PONDS El <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 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 employ persons subject to workman's compensa- <br /> tion laws of California." I �I - <br /> The applicant must call for qqired inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOWbEPARTMENT USE ONLY <br /> Application Accepted by Date p V Are <br /> Pit or Grout Inspection by &ate Final Inspection by - Date <br /> Additional Comments: : <br /> 0 Stk 466-6781 . 0 Lodi 369-36211 0 Manteca 823-7104 El 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' <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE: PERMIT"" 0. <br /> ] <br /> + EH 13-24(REV.1/6 5) <br /> EH 14-26 <br />