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*.r <br /> APPLICATION FOR,PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. Qn <br /> Job Address , a� & d City Lot Size /5` PM <br /> Owner's Name Ct'>d__ ",�.Address `+r? 5� Phone <br /> Contractor's Name �� �l� License No. Phone d✓�G� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DLSPOSAL-FLD.- PROP. LINE ( ) <br /> r. FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS V <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 /> ElPublic El Other ❑ Type Depth of Grout Seal 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION) REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence_ Commercial�/ Other <br /> Number of living units: —/— Number of Abedr�ooums –d <br /> Character of soil to a depth of 3 feet: �1 � _Water table depth Leo - <br /> SEPTIC TANK Type/Mfg � Capacity No. Compartments — --� <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ / <br /> Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE No. & Length of lines d d Total length/size--- <br /> FILTER <br /> ength/size -FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Size Nurpber <br /> SUMPS ❑ Distance to nearest: Well [_cJ Foundation /d Property Line �— <br /> DISPOSAL PONDS ❑ <br /> .� I hereby certify that 1 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 /> hat in the performance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify t <br /> employ any person in such manner as to become subject to workman's compensation laws of ed,I shall <br /> Contractors hiring c sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shah employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must orL;ZZ77�77T-rtle: <br /> rawing on reverse side. <br /> Signed <br /> _zl' Date: 07 <br /> — � FOR DEPARTMENT USE ONLY Q O� <br /> Date � "� Area <br /> Application Accepted by <br /> Date –�� Final Inspection by�4/` re 16� Date <br /> Pit or Grout Inspection by / <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> -�-�' f $4-�S <br /> . EH <br /> 13-24(REV.10/83) INFO <br />