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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> Job Address / ~� City st�l Lot Siz� PM <br /> Owner's Name-Tc S f�ll U Na 5I , Address ,,r 4-ye, Phone <br /> Contractor's Name_L-F,,tz-. \pLAL_TIt en_seNo. 1 T� �+ Phone____v <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 cONSTRf1CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of;Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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 50') � <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V_;*STRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_�__­tommercial_ Other <br /> Number of living units: __V__ Number o edrooms 3 <br /> Character of soil to a depth of 3 feet: �? — - - - Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line I <br /> G <br /> LEACHING LINE 11- .1&Length of lines Total length <br /> i G - <br /> FILTER BED El Distance to nearest: Well /per rFoundation Property Line _ <br /> SEEPAGE PITS E; --Depth '-� Size Number <br /> SUMPS ❑ . Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I c 'IN that in the pe ormance of the work for which this permit is issued, I shall employ persons spbject to workman's compensa- <br /> tion a f California." <br /> The applican call for all equi inspe ons. mp a drawing o erse side. <br /> Signe Title: + /� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date / � Area <br /> . _ _ �.__..___ ..-Date-=� <br /> — t- <br /> Pit-or6rout Inspection by ---- Date- ----- n-bq- <br /> Additional Comments: 1� '_ <br /> El Stk 466-6781 El Lodi 369-3621 El Manteca 823-7104 C1 Tray 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9529V 10 V n <br /> FEE AMOUNT DUE AMOUNT REMITTED C� RECEIVED BY DATE PERMIT'NO. <br /> INFO (/ <br /> + EH13-241REV.10/63) 1 C <br /> EH 1426 _' «� C� ^���Q L'"�-- <br />