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APPLICATION TOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <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/of 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 Q d" City Lot Size PM ` <br /> ' / <br /> Owner's Name Address Phone <br /> Contract Address License N� Phon <br /> _M <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 1-1 <br /> 'TION OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL- "x"PROBLEM AREA­ UCTION SPECIFICATIONS -- <br /> ❑ Industrial' ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing f <br /> ❑ Domestic/Private ❑ Gravel Pack, {. racy t Type of Casing Specifications <br /> I`l Public fi (1 Other f. F1Delta— Depth of Grout Seat Type of Grout <br /> i <br /> I 1 Irrigation pro0Depth I I Eastern Surface Seal Installed by <br /> i <br /> Repair Work Done Type of Pump+„' - '71 H . State Work Done'_ , <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth <br /> i s Fillet Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAmIADDITIONX DESTRUCTION l I (No septic system permitted if public sewer is <br /> ,j��� available within 200 feet.) <br /> Installation will serve: Residence_V_ �'bt <br /> Commercial her <br /> Number of living units: I Number of bedrooms- L t� <br /> Character of soil to a depth of 3 feet: F Water table depth p <br /> w S . <br /> SEPTIC TANK ❑Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 <br /> ' tf� Distance to nearest:. Well Foundation Y'` ioperty LineA Ver- <br /> ti <br /> A7 Y <br /> LEACHING LINE No. & length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Ir0 Foundation _� (J Property Line _ <br /> I � <br /> SEEPAGE PITS h +Depth I JJ14 Size Number <br /> SUMPS ❑ Distance to neatest:. Well 'fes_ Foundation ._ Property Line <br /> DISPOSAL PONDS ❑ <br /> ' ''' <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. y <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 parsons subject to workman's compensa- <br /> tion laws of California." 41 <br /> The applicant st call for all required inspe tions. omplete drawing on reverse side. <br /> Signed X Title: Date: l ^� <br /> J. FOR DEPARTMENT USE ONLY <br /> — �- Date i.. <br /> Appli tion Accepted by Area <br /> �- . <br /> Pit or Grout Inspection by `.; Date. Final Inspect;on by Date <br /> Additional Comments: � P/�/ <br /> ❑ Stk 466-6781 ❑ L 1 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63B5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INI.0 <br /> •.EH 13-21(REV.1/N 5) �V`-�� Ci i"" V f _ G• 1 + V r <br />�., .y EH 14-28 <br />