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4 <br /> APPLICATION PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> App n Ordinance Na.549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Wealth District for a permit to construct and/or install the work herein described. This app <br /> made in compliance with San Joaquin County <br /> Local Health District. <br /> /g U� City Sr11_41ad Lot Size PM <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name <br /> rJ Q��xl <br /> f '.X11.0 License No. Phone <br /> �, f Je ddress � �•'•� <br /> Contractor - <br /> TYPE OF WELL/PUMP: NEW WELL El REPLACEMENT © DESTRUCTION ❑ <br /> - { <br /> PUMP INSTALLATION [I . SYSTEM REPAIR 11 - DTWER-❑ -- -z <br /> SEWER LINES __�- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom LJ Manteca Dia. of Well Excavation <br /> 11 Industrial , t Specifications <br /> l Type of Casing �� <br /> q ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal -Type of Grout <br /> FI Public 17 Other ❑ Delta - <br /> A Depth 1 1 Eastern Surface Seal Installed by <br /> n <br /> 1 1 Irrigation PProx. P State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material IBelow 501 system <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I ],(No <br /> available <br /> o seplwithin 200 feet.) <br /> iUed i( public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms 1-' <br /> Character of sail to a depth of 3 feet: Water table depth > <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ '.T.-71— i Method of Disposal <br /> Distance to nearest: Well Foundation °`m Property Line <br /> LEACHING LINE { M No. & Length of lines Total,length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation s Property Line <br /> i <br /> f� <br /> SEEPAGE PITS i'x Depth --Size—_ 6 Number I <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line 4 <br /> DISPOSAL PONDS ❑ 1._....._ -- <br /> 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." Y <br /> The applicant must call for all required inspections. Complete drawing on reverse side. { <br /> Signed X Title: Date: -7 - 9 <br /> FO DEPARTMENT USE ONLY } i } <br /> Application Accepted by _ Date ? Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date 2 2 <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 /> ffFEE sp UNT DUE AMOUNT REMITTED H RECEIVED BY ` DATE PERMIT ND. <br /> i ! <br /> EH 14-2a <br />