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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 " 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> [PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> r <br /> j (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' 11 q trk City ��root Size, cJ _ PM <br /> Owner's Name Address �` 1���-./ !h Phone <br /> Contractor_A � 4/rz�z Address License No,��Sa�_Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL"REPLACEMENT ❑ DESTRUCTION ❑ <br /> i 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 r TY�E O WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ""°❑ Open Bottom {_1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ElGravel Pack ElTracy Type of Casing Specifications <br /> 1-1 Public ❑ Other _ n Delta Depth of Grout Seal Type of Grout <br /> r <br /> .I I Irrigation Approx. Depth I I Eastern w „ Surface Seal Installed,by - <br /> Repair Work Done ❑ Type of ffump P ..'.' _'Sate Work Done T o <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> {{{ TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if public sewer is 1 <br /> 7L . , - available within 200 feet.) <br /> E N <br /> ;�Installation.will serve:• Residence-�C`o'mmercial:-�. Other-­­­ <br /> Number <br /> ther •@-Number of living units: _>(, Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 Water table depth R <br /> SEPTIC TANK LJ ®Type/Mfg T .1 Y-1, '" - -- Capacity No. Compartments <br /> PKG. TREATMENT PLT. L7" J :. s= r - Method,of Disposal <br /> Distance to nearest: Well�/,00 - Foundation, _...-_.._ Property,Line CJ - <br /> 13. n I ; f <br /> f LEACHING LINE No. & Length of,lines Tota length/size r <br /> FILTER BED ElDistance to nearest: Well., Q.--. Foundation d��2._.- Property Line <br /> J. <br /> SEEPAGE BITS 11 Depth �`� -Size.- . I _ Number Y <br /> SUMPS L� Distance to nearest: '' -well r �� .Foundation .4 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and t4at the work will be done in acc'ordartae with:San Joaquin county ordinances, state laws, and <br /> 1 rules and regulations of the San Joaquin Local Health District., L�. <br /> 'Rome 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",. •Contractdr'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." F <br /> I The applicant must call for all r9quired i pections. Complete drawing on reverse side. i <br /> -Signed X Title: &A-c "gate: l _ <br /> FO DEP MENT USE ONLY <br /> # Application Accepted by r Date Area <br /> 1 <br /> i Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: �� l <br /> ❑ Stli 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Enviro <br /> nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMETTED' CASCK H >-HECEII7ED SY [54TE PENNI)T NO: <br /> i <br /> +.EH 13-24 MEV.I/x 51 —7,c> <br /> EH 1426 <br />