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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA I <br /> Telephone 12091 466-6781 <br /> ,'PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. i t.I , ___F <br /> 72 { <br /> Job Address � City Lot Size �V! PM <br /> Name 'Address Phone <br /> w dress "" """"`L'icense iVo: - Phone I } / <br /> r <br /> Can`tractor <br /> j TYPE OF WELL/PUMP: NEW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -} <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> NSTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> D - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy Type of Casing P <br /> FI Public n Other Cl Delta Depth of Grout Seal Type of Grout <br /> ,} I E Irrigation --Approx. Depth 1 l Eastern S irface Seal Installed by - r <br /> { Repair Work Done ❑ Type gof-Pump--- - - LL H.P.- } State Work Done <br /> i Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth _ P A: filler-Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION 1 1 DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> " t available within 200 feet.) N <br /> Installation will serve: Residence t� Commercial" Other <br /> Number of living units: Number of bedrooms_ <br /> Character of soil to a depth of 3 feet. Water table depth <br /> SEPTIC TANK ❑ -Type/Mfg - 'Capacity . No..,Compartments <br /> PKG. TREATMENT PLT. E) Y r Method^off,D'iispoosall <br /> Distance to nearest: WeII-� Foundation' I�~ Property Line <br /> IVI <br /> a LEACHING LINE_ rsGl No.'Bi Length of lines Total length/size S <br /> FILTER BED "Cly-Distance to_nearest: ell Foundation Z.O_, Property Line <br /> F <br /> SEEPAGE PITS �'l;l ,-Depth Size 6 Number <br /> R SUMPS Ll Distance to nearest: Well 14-D Foundation /2 Property Line <br /> DISPOSAL PONDS ❑ <br /> t 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. k <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 /> employ 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 /> tion laws of California." t l <br /> The applicaA must call for 4pectio'n Complete drawing on reverse side. <br /> Signed X Title: -. Date: V <br /> OR DEPARTMENT USE ONLY <br /> �D <br /> Application Accepted by Date ^� Area <br /> A Y'7 <br /> - �1.0'8' . <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi.,,.369--3621 �O Manteca 823-7104 ❑ Tracy 835-6385 t. <br /> Applicant - 1`16rn all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> � INFO - - <br /> - � f <br /> + EH 1324IREV.kn51 -71 1).<�D ..�✓'w ..+ ... ..� _-.t'Ll -� .. v 7� [`�G .w�..+- �: <br /> at:^�EH 14-29��""r�. r <br />