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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA i <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. t <br /> 7 9 ri 5� lQ! City Lot Size � PM <br /> CJobss �. — Q�?ame �+ Address4 Phoneu, dr 4 AddressW License No. PhoneWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I <br /> FOUNDATION AGRICULTURE�/UELL"" OTHER WELL PITS/SUMP'S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia.'of Well Excavation- Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i — �� <br /> rl <br /> r'] Public C1 Other C I Delta Depth of Grout Seal Type of Grout' <br /> I i Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Mater.al Itop 50'1 <br /> Depth ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l i DESTRUCTION l I (No 'septic system permitted if.public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial— Other j <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depttl of 3 feet: Water table depth <br /> P <br /> v, <br /> Capacity �� No. Compartments <br /> SEPTIC TANK / Type/Mfg P Y y k <br /> 01% Method of Disposal <br /> �y PKG. TREATMENT PLT. ❑ .� »A <br /> Distance to nearest: a Well Foundation Property,:L-ine <br /> LEACHING LINE ' No. & Length of lines �^ Total length/size <br /> x t r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f <br /> In <br /> SEEPAGE PITS i I Depth Size Number <br /> ! t.Zr• y <br /> SUMPS Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4` <br /> hat the work will be'done.inaaccordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and t <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 whii:h this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 /> s <br /> The appiican must calk for all required i spe tions. Complete drawing on reverse side.r <br /> : <br /> Title <br /> Signed X I.Date:, <br /> Q FARTMlENT USE ONLY <br /> Application Accepted by I. DateL ' 1- `U Area I ! , <br /> Pit or Grout Inspection by ate Final Inspection by. ��� Date <br /> Additional Comments: *`// e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 taco 3-7104 ❑ Tracy 835-&385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> w { <br /> FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> INFO <br /> (� I� <br /> +.EH 13-241REV.iiNs1 1 o ` <br /> EH 14-28 <br />