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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT (sem ru. v� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 �� <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1q r r- <br /> Job Address City < Lot Size PM <br /> Owner's Name Ll ---/l Address /-/ ��/ !� r / `�z` Phone , � <br /> Contractor_ /te' /11t_-JAdd,ess / {/:"�� l�'�5/ License No. r �/ r- Phone <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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public r Other H Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 \ <br /> Depth Filler Material (Below 501 _ �l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I>I�. REPAIR/ADDITION I I DESTRUCTION l I Wo 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 f� <br /> Character of soil to a depth of 3 feet: '� Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg '' Capacity /T No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No- & Length of lines Total length/size �! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br />} SEEPAGE PITS Depth Sized Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Di1trict. F <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 /> F 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 must call for all required inspections. Complete drawing on raver a side. <br /> Signed X_ �r/—i-�.�-^- Title: Cj+��T Date: <br /> ✓ FOR DEPARTMENT USE ONLY <br /> Application Accepted by * Date A Area <br />{ Pit Grout Inspection by to /! Final Inspection by 7�Mate L2� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 0 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> `11 <br /> +.EH 1 - - EV.1/85)iK5) ��0 V +[� 3/� 7 2-" v I-19'0 <br /> EH t4-2B "!" i.f 4 <br />