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y V APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (249) 466-6181 <br /> PERMIT EXPIRES 1 YEAR 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 No.549 for sewage or No. 1862for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. M <br /> q «��� eh Lot Size PM f <br /> Job Address � C1�1� C��d i <br /> d1 'j.r �iY1?/J Y,[�f J Address Phone <br /> Owner's Name _ - <br /> ti29D 8/3 1`11-7Phone <br /> Contractor's Name <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> �'�' SEWER LINES DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK !OO — ����,,nn� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 40' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N <br /> i Dia. of Well Casing D, <br /> ❑ Industrial ❑ Open Bottom CJ Manteca Dia. of Well Excavation <br /> DoGravel Pack El Tracy Type of Casing U Specifications <br /> mestic/Private Type of Gro <br /> ❑ Public' y <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> --Approx. Depth ❑ Eastern Surface Seal Installed b <br /> 13 Irrigation �Pq p <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done <br /> ` Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> p Depth Filler Material (Below 501 <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION L1 REPAIR/ADDITION ❑ DESTRUCTION ❑ a�ailableo septiw hit m permitted if public sewer is <br /> Installation will serve: Residence F Commercial— Other <br /> Number of living units: " Number of bedrooms � Water table depth <br /> ' Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> �i r- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Li e <br /> i <br /> SEEPAGE PITS ❑ Depth Size <br /> Number <br /> I SUMPS ❑ Distance to nearest: Well Foundation Property Lin rE v �, AL <br /> HFA!—'" <br /> DISPOSAL PONDS ❑ <br /> I 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 /> 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 ust call for all requir inspections. Complete drawing on reverse slOe. / 8 <br /> 7Z <br /> Signed <br /> Title: Date: <br /> OR DEPA NT USE ONLY <br /> � U Area <br /> Application Accepted by <br /> Date Date q f� f�� <br /> Pit or Grout Inspection by Date Final Inspection by <br /> � <br /> Additional Comments: L,.Q P/ <br /> D Stk 466-6761 ❑ Lodi 369 3621 El Manteca 823-7104 ❑ Tracy 835 6385 t 0` � �:r( <br /> . Stk., CA 9520 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20094 <br /> a ' <br /> FEE AMOUNT DUE AMOUNT REMITTED Z <br /> RECEIVED BY DATE PERMIT"NO., <br /> a INFO. - <br /> .r +EH 13.24(REV.10/83) .;{•- <br /> EH 1428 <br />