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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �`� # �� <br /> Telephone (209) 466-6781J' <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 /> //]] I <br /> Job Address -a "V_ X9,A4AL-A City � Lot Size PM <br /> 411, <br /> Owner's Name Address Phone <br /> Contractor 1 Address �0_ __� f License No.6d76�� Phon _ <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial '❑ Open Bottom C Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Pack ❑ .Tracy Type of Casing Specifications <br /> Fl Puhiic ❑ Other ❑ 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 r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 501 <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is J•/ <br /> available within 200 feet.) 0 <br /> Installation will serve: Residence Commercial_ Other G <br /> Number of living units: . Number of bedrooms <br /> -Character of soil to a depth of 3 feet: A06BE! Water table depth � li <br /> SEPTIC TANK Q Type/Mfg + 21 Capacity 1 No. Compartments 4. <br /> PKG. TREATMENT PLT. ❑ �� Method Of Disposal <br /> Distance to nearest: Well Foundation Property Line + <br /> LEACHING LINE ❑ No. & Length of linesCi r !rtet Tota[ length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation &6_-_,c--7_Property Line _ <br /> SEEPAGE PITS i I Depth`.' Size Number <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t 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 Do-strict. <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 f all required inspections. Complete drawing on reverse side. <br /> Signed X Title: ;Date: <br /> t , <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by eDate & Z7i G Area <br /> Pit or Grout Inspection by Date Final Inspection by date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ <br /> I' ' <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH CK RECEIVED BY DATE PERMITNp. <br /> ♦ EH 1:1-24{fiEV 5) <br /> EH 1426 ,^ <br />