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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 486-6781 <br /> i <br /> !PERMIT EXPIRE&TYEAR 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 we11lpump and the Rules and Regulations of the San Joaquin l <br /> Local Health District. f <br /> �-� City �1 Lot Size PM ! <br /> Job Address <br /> + � Phone <br /> Address <br /> . <br /> Owner's NameCIL <br /> _ <br /> d 2 NALicense No �'2C� Phone <br /> Contractor /'/ Address N <br /> NEW WELL ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: . , WELL REPLACEMENT <br /> —SYSTEM REPAIR-EL-- --OTHER C7' - / �f" •, <br /> r° —'"PUMP"IIVSTP L"LATION" `rt t y �� <br /> SEWER LINES DISPOSAL FLD.S '� PROP- LINE <br /> _ 6'Q <br /> DISTANCE TO NEAREST: SEPTIC TANK , s PITSISUMPS —�- <br /> t i FOUNDATION � AGRICULTURE WELL--=� OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Manteca bia:of;Well-Excavation_.�� -- 11 <br /> �y <br /> Domestic/Private Gravel Pak ❑ Tracy Type of Casing Specifications <br /> of Grout <br /> Ot�,ier ❑ Delta jDepth of Grout Seal L <br /> FI Public 7 - <br /> /�j{� Approx..Depth l I Eastern Surface Seal Installed by <br /> I I Irrigation Ld- r i State,Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> d Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I - Filler'Material (Below 50'1 � ' <br /> t o Depth f,n <br /> } TYPE OF SEPTIC WORK: NEW'INSTALLATION l 1 REPAIfl/ADDITION l i DESTRUCTION I i alvailableseptic <br /> w thin 200 feet.)stem ied it public sew <br /> er is V+ <br /> j Installation will serve:} Residerice— Commercial.. Other <br /> i Number of living units: -Number of bedrooms Water tabletidepth <br /> Character of.soil to a depth of'3 feet t No, Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> r 4 � ~Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ! Property' Line <br /> 1 Distance#to nearest: a Well Foundation <br /> 4 LEACHING LINE ❑ No. & Length of lines - Total length/size <br /> i -Foundation— Property Line <br /> ,FILTER-BED•-~-' ---"'-❑ -'Distance•tonearest:�--Well _- <br /> � l 1 Dept +I � M,Number <br /> SEEPAGE PITS p Size <br /> - µ Foundation Property Line <br /> SUMPS ❑ Distance to nearest: We11 � <br /> DISPOSAUPONDSYr ❑ <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 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 /> to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as <br /> certifies the following: "1 certify that in'the performance of the work for Which this permitisissued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." k L <br /> The applicant m call fol all required pecti1ns. Complete.drawing on reverse side. ��► _,,_1 y� ��� �� <br /> t Title: d Date: '- <br /> Signed X <br /> F-OR DEPARTMENT USE ONLY . <br /> Date '� <br /> Area <br /> F Application Accepted by <br /> Data <br /> Pit or rout Inspection by Date`s <br /> Final Inspection by <br /> Final a <br /> el <br /> Additional Comments: <br /> ❑ Ma <br /> ❑ Stk 466-6781 ID Lodi 369-3621 Manteca S2 ices C] Tracy 835-6385 <br /> Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health <br /> r - <br /> CK RECEIVED BY DATE PERMIT <br /> EEE NO. <br /> MOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> "-3 77p <br /> +.EH 19-24(REV.I n 5) <br /> EH 14-26 <br />