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APPLICATION FOR PERMIT <br /> \ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ,��� <br /> Telephone (209) 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. �]ern <br /> Co—b Address ig c' `e n tee il! City Lot Size PM <br /> t <br /> Owner's Name <Qf Address Phone <br /> f <br /> Contractor�CJ� &, Address License No. ZiKV0.. Phone <br /> f TYPE OF WELL/PUMP; NEW WELL ❑ _WEL-L7'RE LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL__ _ OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA` -CONSTRUCTION SPECIFICATIONS <br /> 1-1Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t ❑ Domestic/Private Ci Gravel Pack ❑ Trac f T , e of Casin <br /> Y Y <br /> --_. P. 9 Specifications <br /> I t'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--. <br /> --- <br /> i I Irrigation _.-Approx. Depth [ 1 Eastern Surface Seal-Installed by <br /> Repair Work Done ❑ Type of Pump H.P. f'— State W rk Done <br /> Well Destruction ❑ Well Diameter Seating Material {top 50'1 N <br /> I Depth Filler Material (Below 50'1- '+ _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1.1 DESTRUCTION No septic system permitted if public sewer is <br /> ailable within 260 feet.) <br /> Installation will serve: Residence_ 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. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nea"rest:­`Well" f Foundation Property Line <br /> A7 r <br /> SEEPAGE PITS € I Depth Size Number <br /> I SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> i <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that t 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 o ' n d 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 pe so in manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol ow I ertify 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 C li i <br /> I <br /> The applicant all required inspections. Complete drawing on r versa si e. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br />} Application Accepted by CAL Date "Z Area ' <br /> i <br /> f" Pit or Grout Inspection by Date Final Insaction by _ Date <br /> f Additional Comments: fI � :A_ <br /> IIII ❑ Stk 466-6781 ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ 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 /> I <br /> I <br /> t FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE 91- <br /> EH <br /> /PERM17'NO. <br /> r.EH 13-21(REV.I/n 51 - r. .` ( /Z�t �.iV to(57o /�"r l <br /> EH 11-28 ✓ V <br /> { <br />