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= APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOGKTON, CA <br /> t 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. <br /> Job Address f "" City. * Lot Sire 0.4r, <br /> PMS' <br /> Owner's Namedr'ss [� tf.—._.- L"�L� Z°11 � <br /> - f � one <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C-] DESTRUCTION 1:1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDEb USE TYPE OF WELL PROBLEM AREA_ CONSTRUCTION SPECIFICATIONS <br />€ ❑ Industrial i ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing Specifications <br /> I`I Public 0 Other Cl Delta Depth of Grout Seal Typ@ of Grout <br /> I I Irrigation i _,.AplfroK, Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done_Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> ji <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO I REPAIR/ADDITION I I DESTRUCTION I I Wo septic syslern perrnined if publicsewer <br /> available within 200 feet.) <br /> Installation will serve: Residence�*-" ommercial_ Other i <br /> Number of living units; T46--••Number of bedrooms _ <br /> Character of soil to a depth of 3 feat: <br /> Water table depth <br /> - SEPTIC TANK! 0-r,-I`ype/Mfg f w r �. Capacity— I <br /> P Y 'I No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well �+�/� Foundation / <br /> {-nrd+— �,(�.._� Property Line .,...—, - <br /> LEACHING LINE &—No. & Length of lines Total length/size - <br /> FILTER BED i l Distance to nearest: Well Foundation—_ Property Line <br /> I <br /> SEEPAGE PITS Wpepth Size Number <br /> SUMPS f L-I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS i1 <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 regu4tions of the San Joaquin Local Health Di§Irict. <br /> Home owner or licensed agent's signature certifies the following: ' <br /> "I certify that in the performance of She,work for which this I' <br /> employ an permit Is issued, !shall not <br /> p y y person g such manner as to become subject to workman's compensation laws of California.''Contractor's hiring or sub-contracting signature <br /> certifies the foil'wing: "f_certify that in the performance of the work for which this permit is issued,I shall em <br /> tion laws of California." ns ploy persosubject to workman's eompansa <br /> The applicant must call for all required inspections. Complete dr wing on reverse side. <br /> Signed zt, <br /> Title: /' !• �., Date: <br /> FOR DEPARTMENT US7wONLY' <br /> Application Accepted by VI �+ <br /> Date i� <br /> 'ItAraa <br /> It <br /> Grout Inspection by Date Final Inspection by <br /> Date�� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmental Health Pormit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT'REMITTED <br /> INFO CASH RECEIVED BY PATE PERMIT NIX <br /> +-RH 13-24 IREY,tix57 <br />