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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 <br /> ,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) j <br /> Application is hesey <br /> b 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 /> 44 L'J City `-•`] Lot Size PM <br /> Jeb Address- � '•T <br /> 1J tj ..(' ddress V d Phone 7 <br /> Owner's Name17�1s <br /> Contractor �'�'� � Address --^ License No,IG 23 7--3 Phone7`G �^► <br /> TYPE OF WELL/PUMP:" NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR ©' OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. t OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> / <br /> +Industrial D Open Bottom ❑ Manteca Dia' Dia. of Well Casing"ot,Well Excavation , <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> [`I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation D-ey�pth l I Eastern Surface Seal Installed by.' <br /> Repair Work DoneLk Type of Puniji H.P. State Work Done�q�I <br /> Well D'es{ruction E2Well Diameter Sealing Material Itop 50') <br /> r t <br /> - Depth Filler Material l6elow 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t 1 DESTRUCTION l 1 (No septic system permitted if public sewer iso <br /> z ', available within 200 feet.) <br /> Installation will serve: Residence' Commercial_ Other <br /> Number of living units: Number of bedrooms t r <br /> Water table depth <br /> Character of soil to a depth of 3 feet:I <br /> � 9 ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t <br /> PKG. TREATMENT PLT. 1. <br /> El <br /> of Disposal <br /> Distance"to nearest: Well Foundation Property.Line <br /> I <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properiy Line Y <br /> i <br /> SEEPAGE PITS I I Depth 1 Size Number <br /> SUMPS Ll Distance +io nearest: Well foundation Property Line <br /> DISPOSAL PONDS C3 } <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 /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's sigature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> n <br /> R ; employ any person in such manner n 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 sliatl employ persons subject to workman's compensa-! <br />,l tion laws of California. <br /> The applicant m t call for all required inspections. Complete drawing on reverse side. 1 <br /> flay I Date: <br /> Signed X _ _- <br /> �»a FOR DEPARTMENT USE ONLY I u <br /> a <br /> Application Accepted by Date ' q — Area <br /> w <br /> 2 fd <br /> Pit or Grout Inspection by Date Final Inspection by� Date <br /> Additional Comments- <br /> D Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> e <br /> FEE AMOUNT DUEAMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> � 3c <br /> " ♦.EH 1321 tREV.1/H 5) � ! '*..,y r- � <br /> L„ EH 11-26 <br />