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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 TY EAR 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 <br /> No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Dist rjrrt.,� v)" Yl <br /> ��% City "r 1 °J1"Lot Size PM <br /> [owner's <br /> Address <br /> NameAddress ✓ PhoneS-C4- F Address License Ho. Phone <br /> ntractor CTION O <br /> PE OF WELL/PUMP: NEW WELL ❑ WELI_'REPLACEMENT ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICU WELL OTHER WELL PiTSlSUMPS j <br /> -INTENDED USE . -TYP.E OF-WELL PRO AREA CONSTRUCTION—SPECIFICATIONS. - r <br /> ❑ industrial ❑ Open Bottom Manteca Dia- of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications t <br /> LJ Domestic/ ❑ Gravel Pa _ El Tracy Yp r al Type of Grout g -_ <br /> t f l Public ❑ O 'rt~ _'❑belts Depth of Grout Sei <br /> Approx. Depth i I Eastern Surface Seal Installed by <br /> I I Irrigation <br /> H P r. State Work Done <br /> Repair Work Do Type of Pump E 1 <br /> I Well Destruct n 1 ❑ Well Diameter} '^ Sealing Material (top 50'1 "" f <br /> f Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ( I DESTRUCTION tiNo septicilable System <br /> m Permfe fitted it public sewer is <br /> _ Installation will serve:w,Residence��Commercial_�._ Other <br /> Number of living units: '� Number of bedrooms <br /> "Water-table depth <br /> Character of soil to a depth"of 3 feet: <br /> j <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> k PKG. TREATMENT PLT. E1- <br /> — <br /> Method of Disposal <br /> t Distance to nearest: Well Foundation Property.Line <br /> Total length/size 41 <br /> LEACHING LINE ❑ No. & Length of lines ; <br /> FILTER BED ❑ Distance to nearest: Well Foundation - Property Line <br /> r <br /> SEEPAGE PITS f I Depth Size _ Number <br /> l SUMPS L-i Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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 Dstrict. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for <br /> ct which this permit is issued, I shalt not <br /> S of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workman's compensation law <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." <br /> Thead X pplicant mu call fo II ired inspections. Complete drawing on reverse side. <br /> Title: � <br /> SigneDate: <br /> OR DEPARTMENT USE ONLY <br /> Date S__—/Y Area <br /> Application Accepted by <br /> Dato final Inspection by � Date <br /> Pit or Grout Inspection by <br /> Additional Comments: Y�e'�1 S �rM 1 4- <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 <br /> -1-3 Tracy 835-5385 <br /> EApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERM I7 NO. <br /> INFO <br /> ..EH 13-24 IREV.t/A$) <br /> EH 14-26 <br />