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APPLICATION FOR PtRMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 1} Telephone (209) 466-6781 <br /> F 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 /> Job Address 1C:J. ?PA_ City a Lot Size � 61 �dekpM I <br /> Owner's NamL�/_ F ddre r <br /> Phone <br /> Contractor IfAddre,, License Na-!/ .? 2rPhone <br /> TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ I <br /> PUMP TALLATION El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; §WrIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 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 ❑ Grave( Pack.. 0 Tracy Type of Casing Specifications <br /> ('I Public Cl Other171pelta Depth of Grout Seal Type of Grout __ \ <br /> 1 I Irrigation _.Approxi Depth I I Eastern $urface Seal Installed by �) <br /> Repair Work Done ❑ Type of Pump H.P.` State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION OMPTE5TRUCTION o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence A . Commercial_ Other �Y VVV <br /> Number of living units: Number of bedroom oll, <br /> r <br /> Character of soil to a depth of 3 feel J <br /> Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , l Method of Disppsal <br /> i <br /> Distance to nearest: Well Foundation"� 100 Property Line 1060— 01 <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation property Line <br /> I <br /> SEEPAGE PITS 11 Depth I SizeF <br /> Number <br /> SUMPS L1 Distance"to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS, ❑ <br /> 1 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 Diktrict.' <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 g such manner as to become subject to workman's <br /> certifies the followingcompensation taws of California. Contractors hiring or sub-contracting signature <br /> : "I c rtify that in the rformance of the work for which this Permit is issued, I shall employ tion laws of 50o7.- i p P y persons subject to workman's compensa- <br /> The applica ca or allfired inspections. Complete drawing on 2vise side. <br /> Signed Title i <br /> - Date: <br /> e . <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area kQL1 <br /> r - <br /> Pit or Grout Inspection by 1 Date Final Inspection by �c� i' <br /> F i i c v Date <br /> Additional Comments: 1 <br /> CI Stk 466-6781 ❑ Lodi 369-3627 ❑ Manteca 823-7184 ❑ Tracy 835-6385 �p I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ` <br /> FEE AMOUNT DUE i AMOUNT REMITTED CK <br /> INFO , 5H RECEIVED BY DATE PERMIT NO. <br /> rl-b ' f <br /> ♦ EH 1}21 IREv,1/n5e J- <br /> EH 11-28 'r <br /> �:20— _f�3 <br />