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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Ici <br /> PERMIT EXPIRES 1`YEAR FROM DATE ISSUED`' ' # <br /> # (Complete in Triplicate) r <br /> # .tri... <br /> Application is hereby made <br /> 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 /> Lot Size PM <br /> G � • <br /> Job Address s_— „;-4i :"iii tt.� ,.a .a cu <br /> r <br /> �, ✓ Address = - Phone <br />� '"• Q,ivner's Name" <br /> ddress X11 L r `f3Dq Phone <br /> Contractor ��� 'License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION LJ <br /> r <br /> PUMP INSTA_LLAT�_01V ❑ Y_$TEM�REP,AI. _ O_T.4fE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> CONSTRUCTION-SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL- PROBLEMAREA <br /> i <br /> L1 industrial Ope <br /> ❑ n'Bottomk "i �'Manteca -Dia-df Well Excavation Dia. of Well Casing !l <br /> ,.--� Pack-- <br /> L1Domestic/Private ❑EGravel ❑ Tracy Type of Casing Scifications <br /> - <br /> ❑ Public ❑ Other ;❑ Delta i0epth of Grout Seal Type of Grout <br /> ❑ Irrigation I-Approx. Depth 1❑ Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done ElType of Pump <br /> H P Sate Work Done <br /> Well Destruction ❑ Well Diameter ! Sealing Material (top <br /> Depth Filler Material (Below 501 TYPE OF SEPTIC WO &�- r <br /> L RK: NEW INSTALLATION ❑ REPAIR/ADDITION ESTRUCTION L] INo septic system permitted if public sewer is <br /> 4 1 Iavailable. ithin_200 feet.) \ <br /> r ' oil 14 r <br /> Installation will serve: Residence Commercial_ OtherL� �� - - <br /> f Number-of living-units:— Number of bedrooms - <br /> t et .� '�A ^ i Water table depth'f <br /> +Character of soil to'a;dep'th;of i3�fe ' <br /> -1 '� r "4 r Capacity No. Compartments <br /> SEPTIC TANK"" 1-1 Type/Mfg y^mom f <br /> PKG. TREATMENT PLT. F1fg Method of Disposal r <br /> Distance to nearest: Well 1 _ :Foundation- Rroperty­!-inei <br /> LEACHING LINE , LlNo, &.Length of lines Total length/size <br /> s u Property Line I <br /> FILTER BED ❑ Distance to nearest: --Well Foundation <br /> SEEPAGE PITS. L�}� r <br /> Depth Size ` Number <br /> x <br /> SUMPS ❑ Distance to nearest: Well I Foundation Property Line <br /> DISPOSAL PONDS 4 <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-ihe following: "I certify that in the perfmance of the work far which this permit is issued, l 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 fa%of Californi <br /> jr- 1 <br /> The appircan must call or all requi d i cti r- Complete dlawing on reverse sid y4 <br /> - '�" I Title: ' Date:" <br /> Signed ,i <br /> .p. FO DEPARTMENT USE ONLY r <br /> r Date Area <br /> Application Accepted by <br /> Pit Grout Inspection by <br /> _'^ e--"D' - fFinal'Inspection byDate - <br /> Additional Comments: <br /> ❑ Stk 466-6781 5 ❑ Lodi 369-36211 �� `❑.Manteca �8J3V104 17 Tracy"'835-6385 x 1 <br /> Applicant;Return alt copies to: Environmental Health Permit/,Services 1601 E.-Hazelton Ave.,,P.O. Box 2009, Stk., CA 95201 , <br /> rr.r X <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED i RECEIVED BY DATE" PERMIT`NO. <br /> INFO <br /> �+EH 13-24 1REV.I/a s> Q�. U. ;,• �• <br /> EK 1426 <br />