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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heteby 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 Addressf �(.-J �� City Lot Size PM <br /> Owner's Name �' ddress ®� �� 3o,3 Phonetf]CJ u <br /> Contractor. Address ��f License IVo. �7+�✓ Phone y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ;�f `` FOUNDATION: AGRICULTURE WELL OTHER WELL PITS/SUMPS xj <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/PHvate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I7 PublicCi Other n Delta Depth of Grout Seal Type of Grout <br /> } <br /> I�!-frrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> a <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ( Sealing Material (top 50') r" <br /> IDepth 1 Filler Material IBelow 50'1 _ _ 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION VREPAIR/ADDITION 1 I DESTRUCTION.I I (No septic system permitted if public sewer is V f <br /> li available within 200 feet.) q <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of�b+edroo is�-3 <br /> Character oft soil to a depth of 3 feet: �+J� � L-64,,7\ c f om Water table depth <br /> V SEPTIC TANK fj�­Type/Mfg SANG- CSO ° Capacity No. Compartments Z 1 <br /> PKG..TREATMENT PLT. ❑ ', E f Method of Disposal <br /> """ry"�`^'='`�'''• <br /> Distance to nearest: w661 r_0_ �ndation� Property Line�_._.. <br /> LEACHING LINE l�o. & Length of lines I Total length/size t <br /> FILTER BED ❑ ,Distanc_e-to�st: �ell os Foundation Property Line77 <br /> Q + �? <br /> SEEPAGCPITS It/Depth —2 Size Number <br /> SUMPS y ! _L.l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ � � I <br /> I hereby certify thI�have prepred this application and that the work will be done in accordance with San Joaquin county ordinancesJ state laws, and <br /> rules and regulations of,.the San Joaquin Local Health District. f <br /> ` - Home owner or,licensed agenh signature certifies the following: "I certify that in the performance oAhe work for which this permit is issued, I shall not <br /> employ any Person in such m nne a4. s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature f <br /> XZS certifies the following: "I cert, i ri the.performance of the work for which•this•permi i is'issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." L--�-- . <br /> The applicant must call f all req red in ctions. Complete drawing on reverse side. y <br /> v Signed X ` 1 Title: rDate: / <br /> tl FOR DEPARTMENT USE ONLY <br /> Application AC1cepted by Date '� Area I i <br /> Pit r Grout I`spection by ' Dat al Inspection by <br /> ae r <br /> P lot <br /> Colments; _,•,•_ <br /> M <br /> ❑ Stk 466-6.81 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ,t <br /> FEE AMOUNT DUE "AMOUNT REMITAO` }RECEIVEI?6Y DATE PERMIT'NO. <br /> INFO <br /> +.EH 324MEV.,/ 51 % � ( 1k 4 L3- © <br /> EH 14- <br /> w <br />