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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA N <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 instal!the work herein described. This application is " <br /> made a compliance with San Joaquin County Ordinance No. 549 for sewage mp and the Rules and Regulations of the San <br /> Joaquin <br /> or No. 1862 for welllpu <br /> Local Health District. <br /> J Q / Q [J City`T PhCl Lot Size 4� PM <br /> Job Address r <br /> T� Address 7 Phone <br /> Owner's Namep b�N ��� _ 6 _ <br /> JAddress License No. Phone <br /> Contractor E— y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA ENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYST REPAIR Q OTHER CJ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER INES <br /> FOUNDATION AGRICUL UR WELL OTHER WELL-- PITS/SUMPS <br /> i <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia-'Of Well Casing <br /> ❑ industrial - El Open Bottom ❑ Manteca ia. of Well Excavation <br /> r T e of Casing y Specifications - <br /> fk ❑ Domestic/Private C] Gravel P k ❑ Tracy Type of Grout <br /> r <br /> 1-1 Public F1 Other Cl Delta De h of Grout Seal <br /> I l Irrigation .--Approx. Depth I 1 Eas rn Suri a Seal Installed by <br /> ' H P State Work Done— <br /> Repair Work Done ❑ Type of Pump <br /> r Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 �- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION' REPAIRIADDITION I I DESTRUCTION E I (No septic <br /> system permiitted if public sewer is <br /> Installation will serve: Residence <br /> Commercial— Other t <br /> Number of living units: Number of bedrooms — <br /> • � � Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Type/Mf �- 6 r Capacity 4 _A_ No. Compartments <br /> is <br /> TANK 9 <br /> r + Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well D A Foundation Property Line <br /> 7 Total length/size <br /> LEACHING LINE $I No. & Length of lines y p <br /> 3 O ,/Pro a Line <br /> FILTER BED El Distance to nearestA well �B Foundation., p �1+ <br /> I - 4, - L <br /> SEEPAGE PITS I I Depth _Size O 8 Number <br /> SUMPS Distance to nearest: Well l �f Foundation Property Line <br /> I _ 'x <br /> DISPOSAL PONDS ❑ <br /> 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 shalt 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;1 shall employ persons subject to workman's compensa- <br /> ftion Jaws of California." y <br /> The applicant t tali to II r fired inspe ons. Complete drawing on reverse side. y <br /> I l Date: <br /> Signed X Title: <br /> 4_0R DEPAbENT <br /> a . <br /> Date_� , /Area <br /> Application Accepted by _ <br /> Date <br /> Final Inspection by <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16.01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 <br /> 1 FEE CK RECEIVED BY DATE PERMIT'NO. <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> + EH 13-24 <br /> c3�j1j 1/ -15--q b D- � <br /> EH 14.29 <br />