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APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 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 /> Application is he+eby made to the San Joaquin Locale Health District for a per to construct and 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/ <br /> pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> ]fL,G6` 0( � _ City 67A2f Lot Size PM f <br /> Job Address <br /> Owner's Name - �_ Address Phone <br /> 3 7S <br /> PLicense No. Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: `t NEW WELL. ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ t <br /> ..-PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE ST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE <br /> :_ <br /> ON AGRICULTURE WELL OTHER WELL' ' PITS/SUMPS <br /> INTENDED USE STYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS + -- -� �""" <br /> ❑ Manteca of We11 Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom I <br /> Pack ❑ Tracy Type of Specifications <br /> El Domestic/Private C] Gravel ;, <br /> '1 Public <br /> -I Other C� Delta Depth of Grout Seal Type of Grout <br /> f " - <br /> I I IrrigIrrigaIrrigation _-Rpproz; Depth l I Eastern <br /> Surface Seal Installed by - <br /> • r H P State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> r Well Destruction ❑ Well Diameter, ; Sealing Material (top 501 <br /> L <br /> Depth Filler Material (Below 541 ' <br /> k TYPE OF SEPTIC'WORK: NEW INSTALLA ION i REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> r r available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms `T g <br /> ....Character of soil to a dept 3'feet: Water table depth Lf` <br /> rSEPTiC.PKG. TREATMENT PLT. ❑TANK L1, Type/Mfg <br /> P"/-- Capacity_��— No. Compartments. <br /> Method of Disposal C� - �� Y � . <br /> Distance to neatest: Well �_ Foun`dation Property Line�� <br /> . *r' I f� <br /> "L130 <br /> EACHING LINE 11�'.No. & Length of lines Total length/sizeDO <br /> 'FILTER.BED ❑ Distance to nearest: Well f _..�_ Foundation _ Property Line — <br /> SFEPAGF PITS { I Depth I - Size Number /p <br /> h rSumps". L7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> MI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, acid <br /> rules and regulations of the San.Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the folkowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Eemploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <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 /> t tion laws of California." <br /> t The applicant must call for all required.inspections. Complete drawing on reverse side. <br /> ` Title: Date: <br /> Signed X — ' <br /> .—F DEPARTMENT USE ONLY' <br /> 4 Date - Area <br /> Application Accepted by <br /> 6 r� Date <br /> Pit or Grout inspection by Date ' '' Final inspection by <br /> Additional Comments: <br /> El Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 '❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P_0. Box 2409, Stk., CA 95201 <br /> FEE „ AMOUNT DUE AMOUNT REMITTED CK GASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> y ✓ <br /> ' +.EH 1324 IREV.t i N 51 7 0,D <br /> �-� <br /> EH 14-28 <br />