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APPLICATION FOR PERMIT „ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT, <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 t <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 /> Job Address It. IL)—., <br /> ' Ci i Lot Size PM <br /> r �� , <br /> Owner's Name - Address �� ��. �J�(/• Phone Y <br /> Contract((r CoAddresslof '2 7 O 1111 � <br /> License No.? _�ZZ�Phane <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 /> El <br /> ❑ Industrial Open Bottom 171 Manteca,:,, Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domesticl Private ❑_Gravel Pack ❑ Tracy t��Type of Casirig.r __ Specifications_ <br /> ❑ Public T❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern _ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump w H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter -Sealing Material itol _w <br /> Depth 11 er_Material,(Belo 50J - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRS ADDITION An DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other s 1 <br /> Number of living units: Number of b d rooms 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg "- 'Ca acit ^' 'r <br /> L' p Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ' Distance to nearest: Well Foundation Pioperty Line'•. <br /> LEACHING LINE Q7 ,No. & Length of lines Total length/size )r , <br /> r <br /> FILTER BED ❑�'pistance to nearest: Well `'"`Foundatiiin p ny Line 1� <br /> �- �� .Pro e <br /> SEEPAGE PITS [D Depth — uNumber— - <br /> SUMPS 11 Distance ell <br /> _ ttFoundation . <br /> ;Y <br /> •;;., <br /> Property Line• �r <br /> DISPOSAL PONDS ❑ <br /> 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." <br /> The applicant ust call for all a ired inspections. Complete drawing on reverse sidg. <br /> Signed Title: f <br /> Date: <br /> ZEPAIRITMI=Application Accepted by 4. <br /> ate Area <br /> 77 <br /> Date Final Inspection by Date C 3 <br /> Pit or Grout Inspection by <br /> OV <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO' CASH <br /> EH 13-24 <br /> p <br /> + EH 14-28/REV.I/1157 l b Ja <br /> g"f <br /> I ` i <br />