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APPLICATION FOR PERMIT <br /> 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �L�fs <br /> fob Address .,.v 4J CityLot Size � � _ PM <br /> V\ Wd <br /> Owner's Name Address _/Yjfa e — Phone 4A6_,k—_ <br /> r <br /> Contractor l Address ,� a 4W License Ni). 2%MPhone <br /> TYPE OF WELL/PUMP: AIEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINES I <br /> OUNDATION AGRICULTURE WELL OTHER WELL_,Y At" PITS/SUMPS <br /> INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTROCTFON SPECIFICATIONS <br /> EJ Industrial ❑ Open Bottom 1-1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> is <br /> ❑ Domestic/Private t XGravel Pack ❑ Tracy Type of Casing Pie Specifications /10 <br /> ❑ Public ❑ Other ❑ Delta `Dep th, f G7out Seal Type of Grout rtC C A <br /> XI '' aatiog ,7�,4pprox. Depth Ll Eastern Surface Seal Installed by <br /> epa rk one ❑ Type of Pump -JtA H.P. 36 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of,3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments . <br /> PKG. TREATMENT PLT. ❑ �. <br /> Method of Disposal <br /> Distance,to nearest-71 Well Foundation Property Line <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest'. Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ` Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring pr 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 subidct to workman's compensa- <br /> tion laws of California." <br /> The applicant mut call for all required inspections. Complete drawing on reverse side. I <br /> Signed { Title: -���_ Date: F �� <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date If "/W!;- <br /> Area <br /> + Pit Grout.nspection by ate l6 Final Inspection by -Date �6 <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, Silk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ;�S— <br /> + EH 13-24iREV.iixs) <br /> " }1-�� � �54��3 <br /> EH 14-28 O Q )'-f <br />