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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE IS <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/o in&the <br /> ;1d <br /> described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for well/pumRegulations of the San Joaquin <br /> Local Health District. <br /> Job Address �" �✓ 1 O A III� City at Size PM <br /> Owner's Name 4 Addresst � <br /> Phone <br /> Contractor �� �¢� Address !!ilr� <br /> erase No. Phane <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 0111 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public Cl Other F 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 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION !.I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200.feet.) <br /> Installation will serve: Rest encs Commercial_ Other <br /> Number of living units: T Number of bedrooms 41 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X Type/Mfg B Capacity J!?-LVO _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal LE i <br /> fe <br /> Distance to nearest: Well��(� Foundations Property.Line /� ♦'�" { <br /> Of <br /> LEACHING-LINE No & Length of lines L <br /> • MCI <br /> Total length/size ©� + <br /> FILTER BED Distance to nearest: Well 10e Foundation_20+'__. Property Line Z 47 , <br /> t <br /> SEEPAGE PITS Depth 026 —Size Number Iff <br /> SUMPS K Distance to nearest: Well #JAV Foundation Property Line !d f" <br /> DISPOSAL PONDS ❑ U, ! f f <br /> f <br /> 1 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: P'certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the followin l 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 Calif, <br /> s <br /> The applican ut all for daequire ie drawing on re rse side. p <br /> �. r' O <br /> Signed X ���� Title:. r Date: � <br /> 4.m FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` i�__es Is — Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: AE ,� Q t% / �y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 0 Tracy 635-6365 A! .� <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH f RECEIVED BY DATE PERMIT'NO. <br /> +.EH13 24 lRtiV,t i n 51 40, y <br /> FH 14-29 7A <br />