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>R. <br /> APPLICATION,FOR PERMIT L <br /> .'.� <br /> 1 SAN JOAaUIN LOCA-5L L HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE.,,STOCKTON, CAS , + <br /> Telephone 52091 466-6781 p p. <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 /> i 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 /> 4 <br /> Job Address 0 f LJ City: r x City Lot Size R2 PM <br /> Owner's Name tJ Address Q' Phone <br /> Contractor Address License No. __Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -` SYSTEM REPAIR­R� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICr - RE:WELL: OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL "pR AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑.Open Bottom Manteca— -Dia:of Well Excavation Dia. of Well Casing <br /> ❑.DomesticIPrivate 0 Gravel P ❑ Tracy Type of Casing Specifications <br /> Cl Public ❑'0 r 12Delta Depth of Grout Seal Type of Grout <br /> I` ❑ Irrigation �pProx. Depth L3Eastern Surface Seal Installed by <br /> Repair Wor .D ❑ Type of Pump H.P. State Work Done_ 0 <br /> Well Destruction '❑ Well Diameter Sealing Material dtop-50'1' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> �.. <br /> Installation will serve: Residence.; commercial, Other <br /> .Ir. V% <br /> i Number of living units: Number of bedrooms <br /> Character'of soil to a depth of 3 feet: ��, �7 <br /> � Water table depth <br /> ter. <br /> SEPTIC TANK X Type lMfg r' _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> gyp. <br /> LEACHING LINE ❑ "No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ i� Distance to nearest: Well Foundation 'Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑t- Distance to nearest: Well Foundation .Property Line <br /> DISPOSAL PONDS ❑ <br /> r <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.. <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." r <br /> The applicant st call for all q fired i ctians. plate drawing on reverse side. <br /> I Sign d 1.6 <br /> Title: Date: <br /> QR DEPARTMENT USE ONLY <br /> .rte .....-- \ j Date: i. <br /> Application Accepted bArea <br /> y 'T <br /> i — _ Data <br /> Pit or Grout Inspection b Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> FEE AMOUNT.DUE. AMOUNT REMITTED ' CASH RECEIVED BY DATE PERMIT NO. <br /> } INFO . <br /> f3 S <br /> + EH 13-241REV. 85) �-74 <br /> EH 1428 <br />