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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hefeby 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/. , l <br /> Job Address 1 �• f'11 City �� Lot Size PM <br /> Owner's Name PFU CSL{ Address <br /> ((�� [� Phone <br /> Contractor. K• C ()A)4tD Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> v <br /> Repair Work Done E] Type of Pump H.P. State <br /> Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: T Number of bedrooms 3 ,1 <br /> Character of soil to a depth of 3 feet: (2_kCrL o6c_ <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ _ y 6 Capacity—_—*— _ _ 4No. Cpmpartments <br /> PKG. TREATMENT PLT. ❑ �� – Methtid of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of fines Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well. Foundation Property Line IS– <br /> SEEPAGE <br /> SSEEPAGE PITS 10� Depth aSize Number_– <br /> SUMPS —' ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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." 4 ; <br /> The applicant r e uir s ctions. Complete awing evei'&e side. <br /> Signed Title, <br /> Date: <br /> FOR DIEPARTMENT OSE ONLY <br /> Application Accepted by --a <br /> v Dateotl: Area <br /> Pit or Grout Inspection by Date Finnal Inspection by 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 Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEF I ___T___--- - <br />