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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 —f <br /> li (Complete in Triplicate) ��� f yy <br /> Application is hereby made to the San[Joaquin Local Health District for a permit to construct and/or install-'the wq k fter�n desi!betl. This application is <br /> ' made in compliance with San Joaquin.County Ordinance No. 549 for sewage or No. 1862 for well/pump an -the R�rl s hAegulations of the San Joaquin <br /> Local Health District. <br /> !, , <br /> Job Address77 - [iV\i t',<rOn,1s� St�� 11C�S <br /> _ City Lot Sik- PM <br /> i } <br /> Owner's Nam i4 Address Phone <br /> Contractor - ' - Address 4 15629Z 4C License'No. &a- Phonate <br /> i TYPE 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 /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial w ❑ Ogen Bottom s ❑ Manteca Dia. of Well ExcavationDia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack t >E3 Tracy Type of Casing Specifications <br /> M Public F) Other I ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation --Approx. Depth I l Eastern f Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Imo - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'I' <br /> Depth t Filler Material (Below 50')" <br /> 3111 TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i.) DESTRUCTION 11.(No septic system permitted if public sewer is <br /> 'available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other T„ 3 ... <br /> Number of living units: N64er of bedrooms <br /> t <br /> Character of soil to a depth of 3 feet: x Water table depth <br /> SEPTIC TANK ❑ T { � - <br /> YPe/Mfg _ - Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ y' <br /> i Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> E }} <br /> LEACHING LINE ❑ No. & Length of lines r`" -- ( Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS C1 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, an <br /> rules and regulations of the San Joaquin Local Health Di§trict- <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 r all requireinspections. Complete drawing on r r side. <br /> Si ned X ' <br /> 9 Title: Date: <br /> I FOR EPARTMENT USE ONLY <br /> Application Accepted by Data <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Dates--a)- <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED <br /> INFO GASH RECEIVED RY DATE PERMIT'NO. <br /> r <br /> +.EH13-24(REV.r i 115 1 <br /> _ <br /> EH 14-2t1 <br />