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-' APPLiCATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> - . . <br /> 1601 E. HAZE.—JON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate),- <br /> Application <br /> riplicate),-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 /> Job Address <br /> r< _ City Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor ' 4"' ddress * / icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> # PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER ❑ ? <br /> i_ d <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLD.� PROP. LINE <br /> TION � L*AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I FOUNDA <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( W 1 <br /> 1 <br /> lk Excavation Dia. of Well Casing <br /> ❑ Indust tial � ❑ Open Bottom ElManteca Dia. of We ! <br /> ElDomestic7Private ❑ Gravel Pack F1 Tracy of Casing Specifications <br /> ❑ Public, ❑ Other ❑ Delta;; Depth of Grout Seal Type of:Grout <br /> ❑ Irrigations --Approx. Depth El Eastern Surface Seal Installed by <br /> ! H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> kA <br /> Well Destruction C] Well Diameter <br /> Sealing Material (top 50') <br /> ( Depth - Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION-❑ (No septic system permitted if public sewer is (� <br /> 4 available within 200 feet.) <br /> Installation will serve: Residence Commercial "L Othei <br /> Number of living units: _ Number of bedrooms'-'.�` y tr4 _ f ( { <br /> Character of soil to a depth of 3 feet: t `� ` Water table.rlepth; ; <br /> SEPTIC TANK ac _ No. Compartments <br /> i � �❑ Type/Mfg= � 1 � � '�� ,�_,, <br /> PKG. TREATMENT PLT. ❑ ,� _ Method of DDspvsal ]�] <br /> ' r Distance to nearest: i Well• Foundation— Property Line 'i <br /> .LEACHIfNG LINE 19( No: & Length of lines Total length/size <br /> 4 <br /> f fII TER BED ❑ .Distance to nearest::, <br /> +Well <br /> Foundation Property Line 1 <br /> f t PANumber <br /> 'r. <br /> SEEG - <br /> Foundation y� �Property Line_ �� <br /> �YI <br /> SUMPS Distance to nearest: 1Well a[ [1.— r.- <br /> i <br /> DISPOSAL PONDS ., ❑ _ - — -. <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, l shall.not <br /> employ any person in such manner as to become subject to workman's compensation laws of.California."Contractors 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 /> rtion laws of California." 3 I <br /> The applicant must call r all re uired inspections. Complete drawing on reverse side. <br /> Signed X, r = ' r Title: z Date:�� <br /> R-DEPARTMENT USE ONLY 001. <br /> Date O 'Area <br /> Application Accepted by <br /> Date Final Inspection by j Date / <br /> Pit or Grout Inspection by <br /> f bAdditional Comments: 1 f <br /> } O Stk 466-6781 ❑ Lodi 369;3621 ❑ Ma riteca 823-7104 ❑ Tracy 835-6385 <br /> 1 ' Applicant - Return all copies to: Environmental Health-Permit/Services 1601 El Hazelton Ave., P.O. Box 2809, Stk., CA 95201 <br /> CKRECEIVED 8Y DATE I PERMIT`NO. <br /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED dCASH- <br /> w ,r+ EH 13-241HEV.7/a51 - (1 <br /> EH 1428 x ' <br />