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J APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., ST.00KTON, CA <br /> Telephone (209) 466-6781 J <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> ¢1 . (Complete in Triplicate) ; <br /> n Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaqui <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 Address 51 / `i <br /> «. City Y �` Lot Size PM <br /> 7 ' CI / <br /> Phone <br /> Owner's Name �h _ Address <br /> f F t <br /> (</ <br /> License No. Phone <br /> Contractor � if f Address 0a / 'V <br /> TYPE OF WELL/PUMP: NEW WELL WELL`'REPv-AGEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION f 1 SYSTEM,,REPAIR 17O,T�HE,� ❑ \��`t <br /> [ DISPOSAL FLD.,t�G�'PROP. LINE �} <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' <br /> FOUNDATION AGRICULTURE WELT. �gg OTHER WELL PITS/SUMPS — v <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR`U5 ION SPECIFI A4,NS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavatjf)n " .Dia. of Well Casing <br /> ❑ Industrial �/ �4 i $ acific�tions d <br /> pomestic/Private Gravel Pack ❑ Tracy. Type of Casing t �: P C <br /> ❑ Delta Depth of Grout Seal �_ Type of Grout _. <br /> I'1 Public [=1 Other } <br /> _.Approx. Depth l I Eastern Surface Seal Installed by �/ --- <br /> - ! 10 <br /> I Irrigation _ _r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> , <br /> Well Destruction ❑ Well Diameter+.: 50Sealing Material Stop 1 <br /> Depth 1 Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I a ailabptic system <br /> ithin m emitted if public sewer is <br /> Installation will serve: Residence Commercial Other <br /> kk Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 2,f Water table depth <br /> SEPTIC TANK EI Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I .f Property Line <br /> Distance to nearest: IIVelI Foundation P Y <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> F Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pe Y „9 <br /> SEEPAGE PITS 11 Depth,'l –Size Number t <br /> SUMPS LI Distancerto nearest: e�[ <br /> Well Foundation �Prpy Linea <br /> DISPOSAL PONDS ❑ } T + <br /> 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 /> r rules and regulations of the San Joag6in Local Health District. <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 10 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> C 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 /> } <br /> The applicant c II for aI requ e t inspections. Complete drawing on r verse side. r <br /> i Signed X — <br /> Title: Date: t <br /> R DEPARTMENT USE ONLY C� <br /> ` Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date— Final Inspection by 1f ._` Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 C1 Lodi 369-3621 . ❑ Manteca 823-7104 O Tracy 835-6385 <br /> Applicant- Return all copies to: Environme t l Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED C SH RECEIVED'BY DATE PERMIT NO. <br /> INFO ����,`� <br /> ♦ EH t3-24 tREY.rin51 .'S� C r � /ti <br /> EH 14-28 l/ <br />