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� I <br /> APPLICATION FOR PERMIT,, <br /> SAN JOAQUIN`,LOCAL HEALTH DISTRICT <br /> "1601 E?HAZES i ON�XVE., STOCKTON, .CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) • <br /> Application is he+eby 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 /> 1 � <br /> Job Address f + City L Si7_7�_ �% ze ' PM <br /> Owner's Name �Jy• <br /> ' Phone P ' <br /> Contractor ��' (dress I License No. 1373.Phone <br /> 6 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ - <br /> PUMP INSTALLATION -SYSTEM REPAIR'❑ - = OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK T 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I IrrigationypApprox. De th i a tern Surface Seal installed by _ <br /> •Repeir Work Done !/ Te of Pump + _ — State Work Done— <br /> Well Destruction ❑ Well Diameter Sealing Material /top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I.I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> available within 200 feet.) w <br /> Installation will serve: Residence Commefcial— Other <br /> Number of living units: Number of bedrooms <br /> Character;of soil to a depth of 3 feeti Water table depth <br /> ' SEPTIC TANK d Type/Mfg Capacity No. Compartments ' <br /> . � <br /> PKG. TREATMENT PLT. L) Method of Disposal <br /> t _" 'Distance to nearest: Well Foundation Property'Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Dapt h�r-?' Size <br /> -SUMPS ` L) Distance to nearest: Well Foundation Property Line- <br /> DISPOSAL PONDS ❑ :!il x <br /> I hereby certifWthat 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 regu o n Joaquin Local Health District. <br /> Home ow or licensed agent ignature certifies the followin : "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ a y person in such mann r as to become ubject to rk en's compensation laws o California."Contractor's hiring or sub-contracting signature <br /> cbrtifies he followin_ certify- t.,in.1he rfo n o e rk f is mot is issued'el shall employ persons subject t workman's compensa- <br /> tl4 law of CalifoFnia.' <br /> The app) ant m t r a quire (ts eta d ing on or er i "N <br /> Signed X lila: Date: <br /> FOR DEPARTMENT USE ONLY <br /> T <br /> Application Accepted.by Date / Area <br /> Pit or Grout Inspection by Date rr y` O Final Inspection by <br /> s <br /> Additional Comments:, ��e �- c� -y car id*ci �. •r' __ <br /> r ❑ Stk 466-6781 © Lodi' 369 1 ❑ Manteca 823 ❑ Tracy 05--63W r o <br /> Applicant - Return all copies to: Environmental Health Pe nit/Services 1601 E: Hazelton Ave., P.O.-Box 2009,}Stk., CA 95201 - <br /> FEE AMOUNT DUE AMOUNT REMITTED ''CK RECEIVED 8Y DATE PERMIY No. ' <br /> INFO CASH <br /> + EH73.24IREV.t/e5) c <br /> t EH 14-26 - 7" _ <br />