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APPLICATION FOR PERMIT <br /> UIN LOCAL HEALTH DI ' <br /> SAN J�A�. STRICT ' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA lv� 1987 Telephone 12091 466.6781 <br /> PERMIT EXPIRES`1 YEAR FROM DATE ISSUED ENVIROMENTAL' HEALTH <br /> �'• - �t r (Complete in Triplicate) PERMIT/SERVICES <br /> t <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. rs <br /> City Lot Size * PM <br /> Job Address <br /> 5 w Phone <br /> Owner's Name 4� � �� <br /> Phon} , <br /> Contractor <br /> S Address - �� License No. , <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> EPAIR <br /> SYSTEM ROTHER, E)PUMP INSYALLATlON ❑ � �s� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK I <br /> FOUNDATION AGRICULTURE WELL. I OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing' <br /> ❑ Industrial ❑"Open Bottom ❑ Manteca Dia. of Well Excavation. Specifications <br /> )Dorhestic/Private El Gravel.Pack ❑ Tracy Type of Casing <br /> D Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El Public Irrigation" Approx. Depth Eastern Surface Seal Installed by <br /> LJ — El . <br /> H.P. State Work Dome _ <br /> ` Repair Work Done C3 Type of Pump: --- — W- <br /> -"` ,"—'-""ll-"`- " Sealin Material (top 50'1 <br /> —Well Destruction ❑ We11 Diameter g f <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK_: NEW INSTALLATION ❑-w REPAIR hADDITION ❑ DESTRUCTION ❑ aNailabptile c system <br /> tem rmiitted 0 public sewer is <br /> � '._Other--r -- <br /> ;;,,,.Installation will_serve:,_Resw idence.� —Commercial-mmerctal.� <br /> Number of living units: Number of bedrooms Water table depth <br /> I" <br /> Character of soil to a depth of 3 feet: �_�,�, �-�-�-.�--^ Capacity No. Compartments <br /> SEPTIC TANK ❑ TypelMfg: r Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance,to7nearest: Well f° Foundation Property Line <br /> 5 I Total length/size <br /> ` LEACHING LINE ❑ No. & Length of Vines 4 <br /> FILTER BED ❑ Distance to nearest: Well ._Foundation Property Line <br /> SEEPAGE PITS ElDepth I Size Number <br /> SUMPS <br /> E] Distance to nearest: Well Foundation Property Line <br /> t -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 /> f 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 shat!not <br /> I employ any person in such manner as to become subject to workman's oompensation 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 r spections. Complete drawing on reve411�2, re. <br /> Title: - Date: <br /> Signed 0 <br /> FOR DEPARTMENT USE ONLY c <br /> P 87 Area <br /> Date <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> ' Pit or Grout Inspection by . <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 5 <br /> i Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> i}I CK# <br /> RECEIVED BY DATE PERMIT`NO,' <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO �nC <br /> + EH 13-24(REV.t/e sl �f <br /> J <br /> EH 14-28 cI <br />