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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZEL—i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> } <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 weupump and the Rules and Regulations of the San Joaquin ' <br /> r <br /> Locale Health District. <br /> `� � Cit Lot Size ger PM <br /> Job Addressa" <br /> Owner's Name <br /> Address 03 v ! W '�-4"- - hone <br /> Z( Phone <br /> A <br /> .rc. Address t� �7 1License No.CantraK-C�� - - <br /> TYPE OF WELVPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 4 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> WI <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout <br /> t f'l Public n Other 171 Delta <br /> Depth of Grout Sial <br /> I I irrigation �_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ -Type of Pump <br /> H P State Work Done_ W <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 r <br /> Depth er Material <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Irl REPAI ADDITION _ DESTRUCTION I I aNailabpti system peithin 1 ee fitted if public sewer is <br /> vle InstaAaton will serve:" Residence' Commercial — Other ! <br /> t Number'of living units: Number of rooms <br /> i Character of soil to a-depth_of_3Lfeet:i� <br /> %1i•>✓� Water table depth <br /> SEPTIC TANK D {Type/Mfg' -s Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest:- -- Well Foundation Property Ljfte <br /> �' o. Leth bf lines <br /> LEACHING LINEN & n ' Total length,'size <br /> Y fir} <br /> . 9 <br /> FILTER BED , x 0-'-Distance�to nearest: .T Well�_..— Foundation ZQ Property Line <br /> /Depth5­----.Size <br /> -- =Size aw Number <br /> I SEEPAGE PITS .` JIiY � <br /> SUMPS <br /> Property Line <br /> $ x�l>� Distance nearest: Well ^/ Foundation <br /> �—� y <br /> DISPOS4U ONDS ❑' �" j � <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 District. ! a <br /> Home owner or licensed agent's sigriafure certifies the following: "I certify that in the-per#ormance of the work for which this permit s issued, I shall not <br /> manner as to become subject to workman's compensate n laws of California." Contractor's hiring or sub contracting signature <br /> employ any parson in such t ersons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this pe�myt is'issued, I shall employ p J <br /> tion laws of California." <br /> The applicant t call for all a uir inspections. Complete drawing on reverVese.Signed X' Title: Date: �7 <br /> 'J P <br /> r FOR DEP RTMENT USE ONLY <br /> ` Application Accepted by Date ` r Area 2� <br /> Fj Date �Fnal Inspection by Date <br /> it Grout Inspection by , <br /> Additional Comments: 4; <br /> ❑ Stk 466-8781. ❑ Lodi 369-3621 . ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i <br /> Applicant.- Return all copies to: Envir�nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> Ng \ <br /> FEECK RECEIVED BY DATE PERMn''NO. <br /> AMOUNT r INFO AMOUNT DUE NT REMITTED CASH /y Z <br /> a EH 13.24 IREV. !J/ ��fn� <br /> EH 14-26 <br />