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11 <br /> APPLICATION.FOR PERMIT . ' - <br /> SAN JOAQUIN LOCAL HEALTH :DISTRICT " <br /> 'i 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> � r <br /> ,,. .� 6 „ „ {Complete in Triplicate). <br /> i <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 welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> y�i ; <br /> J �/V C/�i[/ , SY 1 , t _ <br /> Job Address r /t/Vt.Pc � ,City ,�✓ of Size 7g" Sa - PM <br /> n � <br /> Owner's Name Address Phone `3 " <br /> Contractor Address `a sv- :`'e License:No Phone <br /> LVR,Jj.OF WELL/PUMP: ""' NEW WELL F❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION i❑ [ SYSTEM REPAIR El OTHER ❑ r <br /> DISTANCE TO NEARE PTIC TANK a SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS y j <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS 'S <br /> ❑Industrial ❑ Open Bottom ❑Manteca is. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private EI Gravel Pack ❑ Tracy ; 'I Type o Specifications <br /> 13 Public ❑ Other ❑'Delta Depth of Grout Sea Type of Grout <br /> ❑ Irrigation ---Approx. Depth,. ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.'P:^• State Work Done;� p <br /> Well Destruction ❑ Well Diameter i Sealing Material (top 50') 6 <br /> Depths # Filler Material (Below 501 r <br /> TYPE OF SEPTIC WORK: 36 <br /> NEW INSTALLATION ❑ REPAIR/ADDITION ❑ 0 STR T19N N septic system permitted if public sewer is <br /> ilable within 200 feet.l <br /> Installation will serve: Residence Commercial_ Other <br /> i <br /> Number of living units: � Number of bedrooms # i <br /> Character of soil to a depth of`3 feet: _- c - 'j'%'•f,` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> t£_ <br /> Capacity ' No..Compartments <br /> PKG. TREATMENT PLT. 1-1 ! Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> LEACHING LINE ❑ No�& Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ IN <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 /> 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: # <br /> FOR DEP A TMENT USE LY <br /> A lication Accepted b <br /> Pp p Y Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> `� I <br /> Additional Comment: o F � <br /> ❑ Stk 466-6781 ❑ Lo i 369-3621 ❑ Manteca qf7104 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 /> FEEINFO AMOUNT:DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1429[REV.1/f 51 /+ f( <br /> ,� ii <br />