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1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON_AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �3w <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 /> \ r <br /> Job Address _ \ �' \�u City 7ai Lot Size PM <br /> 7� Owner's Name �co %...G,,0V r Address �- o%APhone <br /> Contractor �� 41 Address - (, Phone <br /> TYPE"OF'WELL/PUMP: NEW WELL ❑ 1 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 /> 4 ❑ 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 t <br /> Well Destruction ❑ Well'Diameter Sealing Material (top 501 <br /> P <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> / 1 available within 200 feet.) <br /> Installation will serve: Residence -- -Commercial— Other M1 <br /> 4.1 <br /> Ilk <br /> Number of living units: f Number of bedrooms <br /> Character°of.soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK .,X Type/Mfg Capacity No. Compartments ' <br /> w ` PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> {� LEACHING LINE ❑ No. & Length of lines Total length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest: . Well Foundation-.L— Property Line <br /> 4', <br /> SEEPAGE PITS ❑ Depth Size t jNumber <br /> SUMPS i ❑ 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 /> V <br /> rules and,reg u lations 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 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 /> The applica ust call for requi d i pections. Complete drawing on reverse side. Sr <br /> r L j <br /> X Signed <br /> Title: �r A r Date: ' <br /> r „^ FOR DEPARTMENT USE ONLY <br /> Application Accepted by vlily]R - Date L- A Y1 Area <br /> Pit or Grout Inspection <br /> /byy ® Date' }.' Final Inspection by Date r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3694211 ❑ Mant ca 823-7104 ❑ Tracy 8354385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO �j A <br /> SH <br /> + EH 1324(REV.1/65) T �� � <br /> EH 14-28 cJ <br />