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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. <br /> Job Address <br /> n rW ` Lot,SizeCity PM I <br /> k, <br /> Owner's Name ' � �[�'/yi Address f�1/ ' - Phone e' '�J' ;! <br /> Y `. - <br /> Contractor's Name A0F!QF.'?/V11 i(-_V if4 ,C License No. `- '— .,t `t Phone .1 21 0.2 <br /> TYPE OF WELL/PUMP, �� NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION'D ti <br /> .. s PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> A I <br /> FOUNDATIONt AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 Uf <br /> INTENDED USS TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El-,Open Bottom _ ❑ Manteca.- —Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private E-1 Gravel Pack ID Tracy Type of Casing Specifications r <br /> x <br /> El Public ❑ Other 4 L) Delta Depth of Grout Seal Type of Grout <br /> C1Irrigation __ -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 1 <br /> -- -1 <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 bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth ` <br /> SEPTIC TANK e-IMfg = trliG!. Capacity ZG_0 No. Compartments °. I <br /> PKG. TREATMENT PLT. C7 1 Method of Disposal <br /> Distance to nearest: Well-,ef�--Foundation %L!-- Rroperty Line L� ' <br /> LEACHING LINE P""Iko. & Length of lines _- ';1 _ Total length/size— <br /> FILTER BED ❑ Distance to nearest: Well.A46I Foundation oe 6. ,° Property-L•ine=r_­�_.._ <br /> SEEPAGE PITS [Depth �� .5ize '.13 t If Number �-- <br /> SUMPS ❑ Distance to nearest: Well -foundation Z Vl �.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 permlt-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 sdb-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 applicantnnust call for all required inspectio C mplete drawing,on reverse side. <br /> Signed Title: Date: <br /> s FOR DEPARTMENT USE ONLY #` <br /> Application Accepted by Date Area r <br /> Pit or Grout Inspection by DateFinal In by ¢ Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT CK <br /> CASH RECEIVED BY DATE rPMRMIT`NO. <br /> +EH 1344(REV.101831 <br /> EH 1428 <br />