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4 APPLICATION FOR PERMIT <br /> f 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. }� <br /> C <br /> I Job Address City � ` -_— Lot Size � <br /> `L� PM <br /> 1 <br /> EtI4 t 1 I/ '/ ddre Phone <br /> Owner's Name ; <br /> .j rL . �' a7 C `l / 3�� Phone_ <br /> Contractor (� Oddress L cense;No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION. ❑ <br /> PUMP I TALLATION ❑ SYSTEM REPAIR'❑ '. t OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ t\ <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> ❑ Industrial ❑ Open Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing A <br /> ❑ Domestic/Private ❑ Gravel Pack I-] Tracy Type of Casing Specifications <br /> [`I Public [I Other ( F1 Delta Depth of Grout Seal Type of Grout <br /> • I I Irrigation __Approx, Depth�,`l I Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump H.P. State Work Done <br /> • -Well Destruction. ❑ Well DiameterY•? Sealing Material {top 501 <br /> l tk <br /> r <br /> `- Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION ' DESTRUCTION I I (No septic sysiem.,pi6rmitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> a <br /> Number of living units: Number of bedrooms <br /> ! Character of soil to a depth of 3 feet: 0 Water table depth <br /> SEPTIC TANK R`Type/Mfg � j; G357L[� -Capacity ..,•—,. _No. Compartments <br /> t PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t t i <br /> > Distance to nearest: Wel{ Foundation 'AC5 Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Lf ..-� Foundation 12(1Property Line <br /> SEEPAGE PITS I I Depth t d J� Size_ _ �� Number <br /> SUMPS ❑ Distance to-nearest: Well 437> r Foundationfo(�,_-_._.._ Property Line <br /> - y . <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 Sari`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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." d <br /> The applicant must call for all;re!5its. Complete drawing on reverse side.Signed Title: /3l t+7✓» Pate: Lam0 FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date 'i Area p it <br /> Pit or Grout Inspection by date Final Inspection by Date 0 10 <br /> ff(t <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 /> Y - _ <br /> FEE AMOUNT DUE AMOUNT REMITTEDffCA <br /> RECEIVED BY DATE PERMIT'NO. <br /> x <br /> IN EH 13.24(REV.F/h 5) J a <br /> r� <br /> .0 w <br />