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APPLICATION FOR PERMIT <br /> SAN,JOAQt11N LOCAL HEALTH DISTRICT v <br /> 1601 E. HAZEL T ON AVE., STOCKTOW CA <br /> Tel'eplione,(209)-466-6781 <br /> PERMIT EXPIRES TYEAAi 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 /> Job Address :a <br /> City L-' Lot Size {. .; PM.. . ' <br /> Owner's Name .` <br /> ` Address _. <br /> PhtNIE7 <br /> _,Contractor „"t,. ... r' .L '° 'Address' r fir' '. ��} .d G License Nares'`` ..TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑PUMP INSTALLATION D DESTRUCTION ❑SYSTEM REPAIR ❑ OTHER ❑DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINESFOUNDATION �--- DISPOSAL FLO:— • PROaAGRICULTURE,WELL OTHER WEt.LpITINTEfVDED U5E TYPE OF WELL PROBLEM A�lFA 'CONSTRUCTION SPECIFICATIONS❑ In 'ustrialOpen Bottom ❑ Manteca❑ OnmesticYPnvate y p Gravel Pack' ' Dla..$f Well ExcavationDia, of �=❑ frac TypeofCasing a "Pubhc `. fl Other f 1 Deka SpecifiDepth'of Grout Seal <br /> I I Irrigation Approx, Depth I f Eastern Type o _ <br /> Repair Work Done .C] Type of Pump H.P.`r. <br /> Surface Seal Installed by <br /> Well DeMructiori State VS ork•Oona <br /> Well Diameter _,� � ' 'Sealing Material (top 50'1• ' <br /> Depth <br /> •Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION I 1 {No sgptic system permitted if.,public sewer <br /> '• available:within 200 feet.l• <br /> Instalfahon will serve: Residenceu I Commercial Other� r <br /> Number of living units: --f-- Number of bedrooms <br /> J <br /> Character of soil to a depth of 3'feet? <br /> SEPTIC TANK: 4 Type/Mfg` µ Water table`de th <br /> t p , <br /> GapacrtyNo. Compartments i <br /> ." PKG. TREATMENT PLT. b '. . . <br /> Method,of Dispose! _ } <br /> Distance to nearest: Well` � Foundation <br /> i Property Line <br /> LEACHING LINE No. & Length of lines " /"` l t. <br /> ` FILTER BSD Total length/size. •% <br /> ❑ Distance to nearest:.. Well F r <br /> Foundation ! <br /> - , Property Line <br /> SEEPAGE PITS Depth, S'ze ►"° <br /> i _,p, <br /> SUMP! i_,.: M... i Numper " <br /> Distance to nearest: Wel! Foundation ,r <br /> DISPOSAL PONDS ~` f� + Property Line E <br /> hereby certifythat I,bave prepared this application and.that the work will be done in accordance with San Joaquin cnunty ordinances, state laws and <br /> rules and regulations of the San Joaquin Local Health Di1trict <br /> Home owner or licensed agent's signature certifies the following I certify that in the performance of the work for which this + <br /> employ any person in such manner as to become subject to workman's compensatioq laws of California_'Contractor's hiring or sub t ontracting signature <br /> certifies the following; "I certify that In the performance of the work for which this permit is issued, I shalt not <br /> tion laws of California. permit is issued,1 shall employ persons subject to workman's compensa-' <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed <br /> • s `�� �'. Title; <br /> Date: <br /> f t nn = A QEPARTMENT USE ONLY _ + <br /> lication Accepted byfr <br /> .. z Date 7 Area r ~� ` <br /> Pit r Grout Inspection by Data <br /> —� mal Inspection by at r7/� <br /> Additional Comments: l <br /> i, © Stk 466-6781 ❑ Lodi .369 3621,6.., ._❑ Manteca:,,-823-7104 C].-Tracy. 835-6385--, <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2008 Stk., CA 95201 <br /> FEE <br /> A» INFO AMOUNT DUE AMOUNT REMITYED>; C r _ <br /> r� '' RECEIVED HY DATE PERMIT`NO, <br /> r,EH 17-24(REV.1/NSI �, h /+ <br />