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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELI ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (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.549 for sewage or No.1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. c / (' ^ <br /> Job Address 69 22 � � �a N City ST1f � Lot Size � AC 1 C PM <br /> 1 <br /> VVIy J����4�+0 12 <br /> "# <br /> Owner's Name �' Address Phone <br /> Contractor <br /> C f I( <br /> I��` Address t ' (_ License No.311 W Phone_ <br /> TYPE OF WELJPUMP: NEW WELL WELL`REPLACEMENT LJ DESTRUCTION LJ <br /> PUMP INSTALLATION ' SYSTiM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> € 1 FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATPN,.S, of <br /> 63 <br /> ❑ 1 ustrial ❑ 0 n Bottom ❑ Manteca Dia. of Well Excavation�S/`wf 4 Dia. of Well Casing <br /> Domestic/Private ravel Pack ❑ Tracy Type of Casing r L Specifications #/2 <br /> ❑ Public y❑ Other ❑ Delta Depth of Grout Seal ��C_L <br /> Type of Grout❑ Irrigation [ 1 �pprox. DeptthEastern Surface Seal Installed byQ L t <br /> Repair Work Done El Type of Pump H.P. <br /> State Work Done Well Destruction ❑ 'Well Diameter Sealing Material (top 501 <br /> TYPE OF SEPTIC WORK:,.-NEW INSTALLATION ❑ . REPAIR/A'D'DITION Cl: 'DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1 t 1 available within 200 feet.) <br /> Installation will serve:. Residence— Commercial— Other <br /> Number of living unit 1 Number of bedrooms <br /> Character of soil'two-a depth of 3 feet: —Water table depth <br /> I SEPTIC TANK f ElType/Mfg Capacity I No. Compartments 1 <br /> Method of Disposal <br /> PKG. TREATMENT PLT. D <br /> ' <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> � } t• <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED — O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS'. Depth t Size Number <br /> SUMPS J ❑ Distance to nearest: ""►7Veil Foundation Property Line <br /> I DISPOSAL PONDS o'-0 <br /> hereby certify that I-Kive prepared this appiicetion°and that the work will be done in accordance witli San Joaquin county ordinances, state laws, and <br /> rules and regulations of•the San,Joaquinbical'Health District. <br /> Home owner or-licensed abent's signature certifies tl<e following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> r employ any person in such.manner as to become subjest•to-workrtan's"cotrlpensation laws of California:"Contractors hiring or sub contracting signature <br /> certifies the following:''I certify L at in1. 'performance of the work for,which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California.... '.) V I' t �, I <br /> The applica m st cal fo II r i i pa io mpl a rawing on re se si e:[`- 4 k�7 Title: Date: <br /> Signed 1C - :• <br /> 1 / fFOR DEPARTMENT USE ONLY <br /> ( Application Accepted by �. Date Area <br /> Pit or Grout Inspection by, <br /> Date Final Inspection by Dat <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑`L:odi 369-3621.1" '❑ Manteca 82.3-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO �7^'xg�gpZ <br /> I + EH 13-24(REV.r/951 <br /> EH 14-28 J <br />