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f ` <br /> APPLICATION FOR PERMIT <br /> T' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601,E. HAZELT16N AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t PERMIT EXPIRES 1 YEARFROMDATE ISSUED <br /> (Complete <br /> 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/ um and the Rules and Regulations of the San J <br /> Local Health District.. _ p p eg Joaquin <br /> Job Address � ` Ir �- f City�� Lot Size PM <br /> Owner's Nar ee 1 C S{IJ.LL�L Address <br /> Phone <br />` ContractorLE s Q <br /> E �A LT��•�i1L Address License No. 3D 9a•- phone ..3 0`�- <br /> F WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEARES TIC TANK SEWER LINES DISPOSAL FLD" PROP. LINE <br /> FOUNDA ' AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PR AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private_ ❑ Gravel Pack ❑ Tracy Type of <br /> w� • ,_•0l- y' , Specifications <br /> ❑ Public I ❑ Other E Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation. ---Approx. Depth F1 Eastern Surface Seal Installed by t <br /> Repair Work Done ❑ Type of Pump p N.P. State Work Done_ I' <br /> Well Destruction ❑ Well Diameter r Sealing Material {top 501 v <br /> Depth Filler Material (Below 5W) -° <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Z--nEPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if, sewer is <br /> e available within 200 feet.) <br /> Installation will serve: Residence•' Commercial L/Other <br /> Number of living units: Numberi'of bedrooms <br /> Character of soil to a depth of 3 feet: -P1 Q SO I Water table depth <br /> SEPTIC TANK a--TYpe/Mfg, Capacity.-JI Q.DJ0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of3i sal <br /> � —Distance'toineare t" Well Foundation Property Line <br /> LEACHING LINE �IQii.'& Length of lines — Tota! length/size~ �r�^� <br /> FILTER BED 7 I F] Distance to-nearest: — Well Foundation_�— Property Line_... ID <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS—,-----.Q­Distance-to nearest: Well Foundation • t0 JC • Property Line <br /> DISPOSAL•PONDS ❑ k , t 3°1 zx s. <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-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 wvrkmah's compensation laws of California."Contractors Hiring or sub-contracting signature <br /> ifies the foli <br /> on a of <br /> o g: ,9certify thafin the-performance of the Fwork�fbr which this permit is issued,I shall employ persons subje t to workman's compensa- <br /> ti .Califor. ` <br /> The plica ust call or al requ d in ctio s. fete drawing reverse 'de. F. { ` ' <br /> i- �-_- <br /> Signe Title: Date: <br /> tie. <br /> ! <br /> I Iy R DFaPARTMENT USE ONLY y <br /> Application Accepted by Date �`f 61 p Area D� <br /> —Pit or Grout ins `� � _ , , <br /> I <br /> pection byDate_ Final Inspection by Date <br /> Additional Comments: �� k <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ^� <br /> INFO RECEIVED`BY DATE ;±PEMIT''N0. <br /> EH 1324(REV.a/s 5)EH 14-28JL <br />