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APPLICATION FOR'PERMIT <br /> 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) <br /> Ef <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 /> i <br /> Job Address w Ci t Size M <br /> zAddress �s 4 Phone <br /> Owner's Name ,, — <br /> Contractor's Name ense No.& Phon / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME � FSTRUCTIDN F-1 <br /> PUMP INSTALLATION_�—_ SYSTEM REPAIR OTHER <br /> DISTANCE TO NE RA EST: SEP',TIC TANK 46J EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS_ <br /> Casin <br /> ❑ Industrial A-9perrBottom ❑ Manteca Dia. of Well Excavati�� g <br /> i9 Pemestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ��� Spec ications <br /> LJ Public E3 Other El Delta Depth of Grout Seal Type of ut <br /> ❑ Irrigation ---Approx. Depth ❑ Ea tern Surface Seal Installed by <br /> f <br /> Repair Work done ❑ Type of Pump I*•P• State Work Done- , <br /> i <br /> Well Destruction © Well.Diameter' Sealing Material Itop 50'1 w <br /> _ Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public'seweis �) <br /> - available within 200 feet.) 1 <br /> Installation will serve_ Residence Commercial Other <br /> ..ar-�+� -.i`:-...�' -ar,-�.af. _.-mss: ys.y�{y, � ..v :-w��•.r-�.--...a-� � TJ��� ..r <br /> e Number of living units: Number of bedrooms j <br /> Character of soil to a depth of 3 feet: Water table depth - <br /> SEPTIC TANK El Type/Mfg Capacity <br /> No. Compartments k- <br /> `� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ) .` <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size U <br /> j'. FILTER BED ❑. Oistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size_ Number ' <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ <br /> fl 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-certfies-the4ollowing:_:I_certify that in the performance of the work for which this permit is issued, i shall not <br /> )' employ any ppeersori'in§uch manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> G, 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 /> The applicant mus i fora required inspeectiom ple wing on reveise side. <br /> Signed Title Date: <br /> FOR DEPARTMENT USE ONLY <br /> t Application Accepted by Date Area <br /> Pit or rou Inspection byt� T at Final Inspection by Date <br /> I Additional Comments:.N 0Z 1 <br /> ❑ Stir 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Heal[Il Permit/Services-11$01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201�� <br /> �-7 w <br /> f FEE AMOUNT DUE AMOUNT REMITTEE- 1 H ' RECEIVED`BY DATE :PERMIT <br /> INFO ' <br /> glopI'71 �' NSD -� g-�Fif .•- <br /> + EH 1324(REv.10/83) <br /> 6 EH 14-28 <br />