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�. APPLICATION4F6113'PE VIR1 1T __ � <br /> SAN JOAQUIN L10CAL HEALTH DISTRICT <br /> 1601 E. HAZE f•ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-67$1 <br /> k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> i � • <br /> Job Address J � _ City Lot Size PM <br /> Owner's Name _ Address — Phone <br /> Contractor, � t�.c t ddress ;� <br /> { C�� v- [.cam 7" `"rLicense Nolil!Q,���z' Phonels�-;,�� <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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF QUELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (57 <br /> F.] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation —_Approx.1'0epth l I Eastern Surface Seal Installed by _ Q <br /> Repair Work Done )4__ Type of Pump Q.&Aetn H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> 1 Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.) REPAIR/ADDITION I l DESTRUCTION I 1 (No septic system permitted if public sewer is 0 <br /> 1 available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Othe-r­``— <br /> ��,� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ( Water table depth <br /> SEPTIC TANK ❑ Type/MfgJ Capacity No. Compartments' ` 1 <br /> PKG. TREATMENT PLT. ❑ I r <br /> ! Method of Disposal <br /> Distance to nearest: Well Foundation Property Line , <br /> � W <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation - Property Line <br /> { <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: WeII Foundation Property Line <br /> DISPOSAL PONDS ❑ n 1 <br /> I hereby certify.-that I have prepared this application and that fh`e work will-Ue done`in accofastice with San Joaquirrcounty_ordinances, state laws, anC <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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 folldWing: "I certify that in the performance of the work for which this permit is issued,Irshall employ'persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant mu-9—call for all required,inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: 7 F0 <br /> .. FOR PEPARTMENT USE ONLY <br /> Application Accepted by Date Area l <br /> Pit or Grout Inspection by Date Final Enspection by - Da[e L <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 INFO AMOUNT DUE AMOUNT REMITTED CASH' RECEIVED BY DATE PERMIT'NO. <br /> +.EH13-24(REV.iiHsl U j <br /> E 4_2B <br /> I <br />