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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> r(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 /> Job Address k1wnCity Lot Size PM <br /> Owner's Name Yt J -Y'r, rr� �'{ ' Address Phone 2 <br /> t <br /> Contractor 9 �'e R Address License No. 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 CONST CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ---❑ Gravel Pack ❑ Tracy Ty of Casing Specifications <br /> f"1 Public ❑ Other { ❑ Delta epth 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 r Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION No septic system permitted if public sewer is <br /> r available within 200 feet./ <br /> Installation will serve: ResidenceCommercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 festa Water table depth C} <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal d <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 /> 4 -.d - <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS ❑ Distance eta neest: Well Foun tion Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application/andAqt the work dKill be done in accordance with San Joaquin county ordinances, state laws, and <br /> i rules and regulations of the San Joaquin Local Health 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 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 /> 1 tion laws of California." <br /> The applicant must call for all required rinspections. Complete drawing on reverse side. <br /> Signed ' 4 C Title:- Date: /0—/57 <br /> U—/ �J <br /> r .f <br /> ARTMENT USE O <br /> I <br /> � <br /> Application Accepted by <br /> a c i <br /> Pit or Grout Inspection by Date Final Inspect/ n by ate <br /> t f <br /> Additional Comments: 'L <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec a23-7104 ❑ Tracy 835-&f85 s <br /> V OF <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE r AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. <br /> INFO ,CASH <br /> + EH 13-241REV.1/85) <br /> EH 14-26 <br />