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t� APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE-, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> [ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �j (Complete in Triplicate) { <br /> V�o <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein escribed. 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 i5_ <br /> Lot SizePM <br /> Job Addressr <br /> Address v— �f Phone <br /> Owner's Name <br /> � dtt�' �'",�'' � e�J--Address <br /> _ License NA // <br /> -Contractor Phoned <br /> -TYPE OFWELL/ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> .DISTANCE TO NEAREST: SEPTIC TANK Ul <br /> OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> aL <br /> INTENDED USE OBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i. Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of t. } <br /> e of Casin Specifications <br /> ❑ Domestic/Private ❑ Grave! Pack ❑ Tracy yP g Typa rout — <br /> I 1 Public f 1 Other - elta Depth of Grout Seal <br /> I 1 Irrigation x. Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump <br /> H.P. State Work Done <br /> Well Destr n f� Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTA LLATION t l REPAIR IADDITION DESTRUCTION { I (Nosep <br /> rwithin 200 feet.)c system + ed if public sewer is <br /> F Installation will serve: Residence 11 Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> F Character of soil to a depth of 3 feet: <br /> E Capacity No. Compartments <br /> k SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT- ❑ L <br /> Distance to hearest: -Well Foundation Property.Line <br /> LEACHING LINE L1No. & Length of lines Total length/size <br /> FILTER BED El Distance. to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS { I Depth Size Number <br /> SUMPS Ll Distance` to nearest: Well Foundation Property Lime <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 DFstrict- <br /> ork for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the w <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: "1 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." # Q L <br /> The applicant st call for all required in ctions omplete drawing on rUyse side. <br /> de: a y Date: <br /> Signed X Ti <br /> /7 <br /> l EPARTMENT USE ONLY <br /> Date1���� Area' L <br /> Appli ron Accepted by --Pit or Grout Inspection byDateFinal Inspection byDate 3 :67 , <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 "' <br /> Applicant -.Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 .4 � <br /> tr CK RECEIVED BY DATE PERMIT'NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INF <br /> +.Eii 13-24(REV:rirsal �.CJcJ �� (J L/ <br /> EH 14-28 <br />