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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <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 instaN 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 /> ®/ cty— Lot <br /> /J� X42 <br /> Job Address Lot Size�"�2! — PM <br /> Owners Nam Address <br /> Address � '�'"� <br /> Contractor d Address -�"=-�- License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> I NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER G <br /> DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. UNE _. <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> Industrial D Open Bottom ❑ Manteda Die. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private - C Gravel Pack ❑ Tracy-1 ,Type of Casing Specifications , <br /> Public Other `..� Cl Delta Oepth of Grout$eems Typs_of Grout <br /> j ❑ Irrigation ---Approx.,Depth 71 Eastern Surface Seal lrstawd'by— <br /> Repair Work Done D Type ofm <br /> :Pup "H.P. r State Work Dona <br /> Well Destruction G Weil Diameter ( Sealing Material(top SO') — <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI N ❑ REPAIR/ADDITIO DESTRUCTION O INC septic system permitted B public sewer is <br /> ava�7abld within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other 1 <br /> Number of Irving uniss: --/— Number of bedrooms <br /> Character of soil to a depth of 3 feet: 00 T Water table depth and <br /> SEPTIC TANK 2 Type/Mfg Capacity No. Compartments _. <br /> ` PKG. TREATMENT PLT. C _ ,� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE �X,No. & Length of lines / fdg�L7 Total length/si <br /> FILTER BED a Distance to nearest: Well Fou tion Property LIne <br /> SEEPAGE PITS , Depth Sue — Number f ��� <br /> SUMPS_ Distance to nearest: Well _ Foundation`Q ,- Property Line s5 : <br /> DISPOSAL PONDS r—r'--T `=F - <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 Heahh District. <br /> Home;owneror licensed agent's signature ctifi <br /> eres the following:"I certify that in the performance of the work for which this permit is issued, I shag not <br /> ampby any person in such manner as o'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 oftthe work for which this permit is issued,I shall employ persons subject to workman's Corrgensa- <br /> A _tion-taws of California." <br /> TFe-applicant I it for 11 required inspections. Complete drawing on reverse side. <br /> S good <br /> —__ <br /> Title: /R Date: <br /> r DEPARTMENT USE ONLY 1pL� <br /> A lication Accepted by - "�as�- �Data 41;3Area-�---1 <br /> --'"1' - �� )_ <br /> Grout Inspection by Oate oZ�'� Final Inspection by aro <br /> P <br /> Additional Comments: <br /> = Stk"4S6E7g1-0-todIi–A9-9S21 ❑ Manteca 873-7104 ❑Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 55201 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED DASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> D ,gym <br />