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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> s 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�J3 � f�r ���!}S �4/✓�1�45 <br /> I �` �fCity t of Size / 1� PM <br /> 1 2.Job Address 5 <br /> --fCy (�}Q/yt Q V6r Address Phone <br /> Owner's Name <br /> Contractor_ f`� —Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUCTION 1) <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> ' DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS x Dia. of Well-Casing <br /> Industrial Bottom--- L] Manteca Dia--of Well-Excavation- <br /> - - <br /> ❑ Indust p S ecifications <br /> Type of Casing <br /> ra• ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> - Type of Grout — <br /> ` ' f1 Delta Depth of Grout Seal <br /> al Public ❑ Other <br /> --Approx. Depth l 1 Eastern Surface Seal Installed by <br /> I f Irrigation State Work Done— <br /> RepairWork Done - ❑ Type of Pump H.P. <br /> �y <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50`i <br /> Depth, r Filler Material IBelow 50'1 . <br /> t TYPE,OF SEPTIC WORK: NEW <br /> INSTALLATION ALLATION REPAIWADDITION.I 1 i)ESTRUCTION 1 I availab etrw thin 200 feetc system iued it public sewer is w <br /> i Installation will server Residence` commercial- <br /> Other <br /> .- <br /> Number of living units: 4— Number of bedrooms Water table depth t <br /> Character o�soil to a'depih of 3 fe t: "�� i <br /> Capacity ± 'No..Compartments <br /> SEPTIT e/Mf r C'TANJ< ❑ Y.,A,.+ 9 Method of Disposal i <br /> PKG.iTREATMENT PLT. ❑ ., ry t ' /` <br /> piston)a ioRnea est: 'Well Foundation_ �— Property Line <br /> �en'th'of lines Total length/size <br /> i LEACHING UNE Ig'yNo. & L 9 <br /> [I FILTER BED <br /> C1 Distance to nearest: Well Foundation Property Liner` ) <br /> SEEPAGE PITS 11 Depth Number <br /> Cl Distance to nearest: Well Foundation'`,i- �'IP,roperty Line F t <br /> SUMPS <br /> DISPOSAL PONDS ❑ a <br /> I hereby certify that I have prepared this application and tf�at the work will be-done in 6bcor0ance with.SanJoaquincounty ordinances, state laws, and <br /> rules and regulations-.of the San-Joaquin_LocaLHealth [3itrict, <br /> Hsignature <br /> ome owner or licensed agent's sigriature certifies the following: "I certify that in the performance of the work,for_which this permit is issued, I shall not <br /> j employ any person in such manner as to become subiect to workman's compensation laws of California."Con4race�sonslsub ecrt to wo�kman{scampensa- <br /> rr certifies the following: '9 certify that>,in'the performance of the work for which this permit is issued,t shall employ p I s <br /> tion laws of California." r a <br /> The applicant must call fo all aqui d inspections. Complete drawing on reverse side. F: <br /> i Date: <br /> Signed X 1 Title: s <br /> r <br /> R DEPARTMENT U,SE ONLY <br /> ¢ Date Area <br /> j Application Accepted by Jf/� <br /> If t rDate Lam!— <br /> Pit or Grout Inspection by Data Final inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781•---C1-Lodi 369-3621.> –G7 Manteca -823 7104{ ❑ Tracy ,835-6385 g <br /> Applicant'-.,Return all copies to: Environmental Health PermitAervices 1601 E. Ha feltori Ave., P.O. Box 2009, Stk., CA 95201 <br /> " «FEE: .. CK. -^�-;--RECEIVED,BY "" ""' tSATE" �_•.'PERAAIT NO„ <br /> INFO —AMOUNT-DUE­ —AMOUNT CASH <br /> +tEH 1321 PREY.$/H5) <br /> i•.• <br /> EH 14-28 - <br /> 5 <br />