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APPLICAT ON <br /> FOR PERMIT <br /> r d SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> / 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Y <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. 1662 for well/pump,and the Rules and Regulations of the San Joaquin.: <br /> Local'Health District. . <br /> Job Address �7 d 3 LGn0 _ City Sn\L Lot Size*3;4 PM <br /> v Owner's Nametia An( <br /> Address 7 U- Phone D , <br /> Contractor L Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ c• <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FED. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <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 /> I'1 Public n Other n Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.Approx. Depth f 1 Eastern Surface Seal Installed by t <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 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION i I (No stem septic system V permitted if public sewer is J. <br /> available within 200 feet) <br /> Installation will serve: Residence_ Commercial— Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:/ Water table depth * ; <br /> SEPTIC TANK ❑ TypelMfo: Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl 4;I Method of Disposal ; <br /> Distance to nearest: Well Foundation . Property Line <br /> LEACHING LINE No. & Len th of lines - l3 <br /> 9 .,._ Totallengthlsize <br /> FILTER BED 1-7 Distance.tb nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ! Depth _ �� $ize —2n, Number <br /> SUMPS i_I 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 Di1trict.' ! <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 or sub-contracting signature-4 <br /> certifies the following: "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 /> tion laws of California." <br /> r <br /> The applicantmust call for all req 'rod inspections. Complete drawing on reverse side. <br /> x Signed X tt Title: Date: _ <br /> /1 r FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 5Ar a 5 ! <br /> Pit or Grout Inspection by Date Final In ct' n b <br /> Date <br /> Additional Comments: <br /> 1 i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant 823-71 ❑ Tracy 835-6385 4 <br /> Applicant - Return all cop' s to: Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.O. Boz 2 Stk., CA 95201 <br /> Je <br /> J /f <br /> �6i+c-/[¢�_a✓ 4-/�7. <br /> INFO AMOUNT DUE .� AMO--UNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 14-26 <br /> + EH13-24(RE V.iiHsi �� l/1 /lL [' ,,.r/2 XyR-Ar <br />