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APPLICATION FOR PERMIT j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 <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 No. 54.9 for sewage-or No. 1862 for wen/pump and the Rules and Regulations of the San Joaquin 1 <br /> Locale Health District. �i i } <br /> N; Y City.�rl- Lot Size PM 1 <br /> Job Address �` Q <br /> Phone <br /> Owner Name <br /> �P,rryy�@_, {�itl'l 4�� Address <br /> Contractor O Address License NoPhone <br /> TYPE OF WELL/PUMP:'.. ?: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST:_.SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS <br /> INTENDED USE <br /> " "PROBLEM AREA CO —_ CTION SPECIFICATIONS <br /> [JIndustrial ElOpen Bottom ❑ Manteca . ,of Well'Exca%ation Dia. of Well Casing <br /> 11 Domestic/Private ❑ Gravel Pack _,E] y,.�,., <br /> Type of-Casing F - r — - - Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ox. Depth ❑ Eastern Surface.Seal installed by <br /> Repair Work Done ype of Pump H.P. State Work Done_ <br /> Well Destru In ❑ Well Diameter Sealing Material stop 50'i "f <br /> Depth ..Filler.Material-.(Below-50'), —' <br /> F <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 17REPAIR/ADDITION ElDESTRUCTION No septic system permitted ubhc sewer;is <br /> „�„2 ,�...»�•� - - AVailable within 200 feet.) <br /> Installation will serve: Residence; Commercial— Other <br /> a- :� a s.. .s ..s <br /> Number of living units: _y-Number of bedrooms <br /> Water table depth ' <br /> Character of soil t a depth of 3'feet: ,. - <br /> SEPTIC TANK Type/Mfg Capacity— <br /> PKG. TREATMENT PLT- ElMethod of Disposal <br /> Distance to near ell Founda Property Line <br /> LEACHING LINE '5 No.& Length of lines Total length/size <br /> k FILTER BED ❑ Distance to neares- Well foundation Property Line <br /> i <br /> a SEEPAGE PITS ,. :�, <br /> Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line ` <br /> f <br /> DISPOSAL POND ❑ <br /> I hereby certify that I-have prepared this application and that the work will be done in accordance with San Joaquin county ord{ 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.' <br /> The applicant mus all for all required inspections:-Complete drawing-on rse'side:. _ -. - <br /> i, Signed X� ��� Title: Date: �� 7 - <br /> IFOR DEPARTMENT USE ONLY ° <br /> Application Accepted by Date rea <br /> 1 Pit o'Grout Inspection by t <br /> Date Final Inspection by `- Date <br /> i Additional Comments: <br /> ❑ Stk 466-6781 ❑ Loi 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO { <br /> + EH 13-24 IREV.1/a b7 <br /> EH 14-28 <br />