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.• APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> 4 <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 a plication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the Sn Joaquin <br /> Local Health District. <br /> Job Address <br /> P, V <br /> CitySize PM <br /> Owner's Name E J� U Address s8 Phone <br /> Contractor L- Address t License fVa. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION r]' SYSTEM REPAIR ❑ '_ OTHER ❑r <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4. 'DISPOSAL FLD. PROP. LINE <br /> 3 FOUNDATION AGRICULTURE WELL OTHER WELL—}PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal r Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done,. ❑ Type of Pump H.P. F State Work Done r � , <br /> Well Destruction F-1WeII Diameter Sealing Material (top 50'1 <br /> q Depth Filler Material (Below 501 O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> r t i available within 200 feet.) <br /> Installation will serve: Residence Commercial Other Z {- <br /> Number of living,units: <br /> Number of bedrooms <br />� Character of soil`to a depth of 3 feet: <br /> } � � Water tattle depth 0 <br /> SEPTIC TANK;1 El1 Type/Mfg r fl?.]i�� ✓ Iv Capacity_.— No. Compartments .11 <br /> PKG. TREATMEJ PLT, ❑ �? 3 Method of Disposal ` <br /> Distant to n aresf. Well Foundation Property Line <br /> 1 • <br /> vi R <br /> LEACHING LINE, S?'-i No: & Length of lines , Total length/size r� <br /> + ' V <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t t l <br /> SEEPAGE PITS Depth❑ tDepth `" "Size` Number <br /> SUMPS., f ❑ Distance to nearest: Well ` Foundatioi Property Line <br /> DISPOSAL PONFDS ❑ <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-Heaith`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 /> I 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 followi` "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 /> i, �ttpra`a�ws of California.Wallequir <br /> The appTC must,"" nspecti s Com ete drawing an verse std . <br /> .Title: Date: <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate f r Area <br /> -- Pit or Grout inspe io(n�y "" ---Date Final"Irispection by <br /> Addit naI Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385, <br /> Applicant- Return all copies to: Environ ental ealth P rmit/Se foes 16A E. Hazelton Av P.O.'Box 2009, Stk., CA 5201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ti RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t + EH 13-24(REV.1/85) IT°0 ZW -1 t—$� Y5-13) <br /> EH 14-2$ <br /> i <br />