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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-67131 <br /> PERMIT EXPIRES 1 YEAR FROM DATEJSSUED,- , <br /> . -(Complete in Triplicate),,u <br /> .h Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work 6erei n 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 Rulesbrid Regulations of the S I an Joaquin <br /> r ."Local Health District. t 11 -7 36 <br /> Job Address llot size *re PM <br /> City <br /> e Phone <br /> Owner's Name <br /> _ Add e <br /> T -A <br /> te <br /> Contractor Address LLicense No. % Phon <br /> e <br /> — <br /> TYPE OF WELLIFUMV: NEV. WELL_�K. WELL REPLACEMENT 0 DESTRUCTION"C1 k <br /> ,4 -REPAIR.0 OTHER U <br /> PUMP INSTALLATION 0 S YSTEM 10-171 - <br /> A. tDISPOSAL FLD.— PROP.–LINE. I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. —"i�P_ <br /> 1% 1 . - fPITkSUMPS <br /> FOUNDATION AGRICULTURE WELL OTLHER WELL <br /> INTENDED USE t TYPE OF WELL t PROBLEM AREA v, CONSTRUCTION ZPECIFICATIONS <br /> Dia. of Well Casing <br /> 0 Industrial 0 bpeh"gottorn I" Dizf. of Well'Excawation.' <br /> A� —_L &� tk <br /> 0 Tracy Type of Casing RV I Specifications <br /> Domestic/Private 0 Gravel Pack Type of Grout <br /> 0 Delta Depth of Grout Seat at 9 <br /> E3 Public 0 Other Uv,r <br /> 0 Irrigation' #5--App,o-. Depth 0 Eastern ♦ Surface Seal lnstalledfby kK-be'ff�e <br /> k. ..;� H'P. Q- I­* <br /> Repair Work Done 0 Type of Pump ,%L — Stdte Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 501 <br /> Depth it 57 tl Filter Material (Below 501 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 1, DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: — Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK F1 Type/Mfg Capaci 3 <br /> PKG. TREATMENT PLT, U Method of Disposal <br /> Distance to rieaiest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE 0 No. & Length of lines <br /> .. <br /> FILTER BED 0' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 0 Depth, Size Number <br /> to Property Line <br /> SUMPS ..F] Distance tnearest: well Foundation Proper <br /> DISPOSAL PONDS L3 <br /> I 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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature ce -contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub <br /> certifies the following:"I certify that in the performance of the work fot which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> r The applicant;pust call for all requir ilogn <br /> 5s 1:Efo?blate drawing on reverse side. <br /> . <br /> 44� , <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Date /Application Accepted by 7 Area <br /> k <br /> I Pit or Grout Inspection by Date. Final Inspection <br /> Date <br /> Additional Comments. rw <br /> k 0 Tracy 835-6385 <br /> El Stk 466-Ml i 0 Lodi 3621 El Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box,2009, Stk., CA 95201 <br /> .'RECEIVED By DATE PERMIT'NO. <br /> FEE ED kX" <br /> A;MOUNT DUE, AMOUNT REM CASH <br /> INFO <br /> + EM 13-24 IREV.WH 5) <br /> EM 1428 <br />