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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 '('YEAR FROM DATE ISSUED <br /> I <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 Jdaquin 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 /> I <br /> Jab Address f� y+� s City � /1-7'0A)Lot Size PM <br /> n­.,...•.. �I <br /> L�ommJlercialLJ rlrailer <br /> Apartment House <br /> Installation will"sere: ` Other-._ "'----" ---Residence <br /> TYPE OF WELL/PUMP: i�i NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D <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 O <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing } <br /> ❑ Domestic/Private - ❑ Gravel Pack ❑ Tracy Type of Casing Specifications \^ <br /> I l Public D Other 1� Delta Depth of Grout Seal Type of Grout V1 <br /> I Irrigation 11`Approx. Depth I I Eastern Surface Sea$ Installed by <br /> Repair Work Done ❑ Typeof Pump H.P. State Work-'Done_., <br /> Well Destruction ❑ WeII�Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 505 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION LI DESTRUCTIONY IN septic system permitted if public sewer is <br /> lavailable within 200 feet.I <br /> Installation will serve: Reside ce_ Commercial— Other <br /> Number of living units: Number of bedrooms <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. ❑ " d�� v Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE El- N'o. & Length of lines Total length/size <br /> FILTER BED ❑ Dilstance to nearest: Well Foundation Property Line <br /> �`` i <br /> SEEPAGE PITS 1 I DBpth Size Number <br /> SUMPS L-i Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �� x ^°°-o^ - •- �- <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 Sar'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." I' <br /> The applicant mus all for all required inspections..Complete drawing on reverse side. <br /> Lz- hSigned Title: D/.0 f Date: <br /> FOR DEPARTMENT USE ONLY W <br /> Application Accepted by A(H Datel Area <br /> Pit or Grout Inspection by . Date Final Inspection byDate 0_/ <br /> N. <br /> A ditional Comments: F <br /> 5tk 466-6781 ❑ Lodi-1 969 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> A cant- Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Slk., CA 95201FEE I <br /> .I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> yF 1L - <br /> + E4i 13-241REV.1/x51 �.�CD <br /> --I-2_� 2 <br /> EH 14-26 ` S <br /> I� <br />