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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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address I-/`i t7lam' '-� '� ,- City_zv ? Lot Size 4AN a PM <br /> Owner's NameAddress Phone <br /> �� 0 <br /> Contracto ` �� � Address �< License No./ Phone <br /> Y TYPE OF W LOP M 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 CONSTRUCTION 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 a� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 91.D <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewrr is 0 <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:J_ Number of bedrooms \17�7 <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 X(: Property Line <br /> r� <br /> LEACHING LINE A No. & Length of lines f Total length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: Well ­nyv Foundation q0 Property Line �4 C2. � <br /> SEEPAGE PITS $ Depth Size Number , <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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." 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." v <br /> The applicant must call for all uired inspeccttiigns. Complete drawing on re erse side. <br /> Signed X �s �'�'t '* Title: 1 f a`�+?✓?ir — Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date1� _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO ) p <br /> '�+EFi 13-24(REV.i/as) �..�� C <br />