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APPLICATION FOR PERMIT <br /> if SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I1 <br /> ssuED ► � RP ,��G <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 her c This application is <br /> made in compliance with San Joaquin County Ord" ance No. 549 for sewage or No. 1862 for well/pump and the Rules ans of the San Joaquin <br /> Local Health District. D tP S'o~o <br /> Job Address A SIFERT _OEF <br /> City. Lot Size PM_ <br /> Owner's Name r� AddressPhone Q <br /> } Contractor reSSAtcense N Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPL CEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> — "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DlSPOSA"L FCD `";PROP.LINE"�'' <br />` FOUNDATIONPb IfE'AGRICULTURE WELL : OTHER WELL PITS/SUMPS <br /> If INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial "❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f1­1 Public D Other C I Delta <br /> Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth f I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> k Well Destruction Well Diameter y <br /> Sealing Material (top 50') ._AhFx . <br /> Depth Filler Material (Below 50') A <br /> TYPE OF SEPTIC WORKc' NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is �} <br /> I available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth O <br /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> P Y No. Compartments i <br /> PKG. TREATMENT PLT. ❑ a <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE I <br />_ ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line I <br /> SEEPAGE PITS f I Depth Size 'Number Z <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS 1-1FoundationProperty Line <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 Di§trict. <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 of sub-contracting signature <br /> certifies the following: "I ce ify 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 Bfornia." ' <br /> The app' T1 111 all req r inspect-ons. Complete drawing on 6 arse side <br /> Signed X f <br /> Titl Dater <br /> FOJR EPARTMENT USE ONLY" <br /> Application Accepted by f' <br /> Date r Area <br /> Pit or Grout Inspection by Date Final Inspection by IbA \ <br /> Data / / 0 <br /> Additional Comments: — C ;& <br /> ❑ Silk466-6781L1 Lodi 369-36210 Manteca 3-7104 ❑ Tra 835 fi365 <br /> AAW <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, 5tk. CA 95201 <br /> 30 <br /> _.q- <br /> rn,X ;Zt33 ._3:3t5 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 1REV.1/e 51 v u <br /> EH 14-26 YY jj// pp��" tGr f�q <br /> l7 <br /> 2-7/I- ? . <br /> �:/� <br />