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APPLICATION .FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH-,DISTRICT <br /> t <br /> 1601 E. HAZELTON ON 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 /> City.. ;1 Lot Size � PM <br /> Job Address � •i tw•sA •.`> ((ff ��� ' <br /> Owner's Name — <br /> Address �� F� _-- - Phone L ' <br /> r 4!� ,�l <br /> Contractor _ ._Address/.!"�_ —License NXO'S- Phone�W� - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT J DESTRUCTION ❑ <br /> PUMP INSTALLATION F1 SYSTEM REPAIR ❑ OTHER D <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 J Open Bottom i 1 Manteca Dia. of Well Excavation Da. of Well Casing <br /> El <br /> O Domestic/Private C Gravel Pack L i Tracy Type of Casing__ _. _ Specifications <br /> El Public F, Other Cl Delta Depth of Grout Seal Type of Grout_ r <br /> L! Irrigation 1 .—Approx. Depth 1 Eastern Surface Seal Installed by_ — <br /> Repair Work Done I I i? ',Type of Pump _ H.P. _. —". <br /> _ State Work Done <br /> f Well Destruction G. ";Well Diameter —,--Sealing-Material-(top 501 <br /> Fil r Material (Below 50') <br /> ,TYPE OF SEPTIC WORK: NEW INSTAL TION . REPA R/ADDITION DESTRUCTION 1 IN septic system permitted if public sewer,is e. <br /> Lq Pe n <br /> 4 i 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: r s i - '" Water table depth i� ~- ' <br /> en -­ <br /> % <br /> SEPTIC TANK %` ��ype/Mfg — - — CapacityL ff� — - No. Compartments <br /> PKG. TREATMENT PLT. C t f �• x Method of Disposal _ <br /> t� Distance to nearest: Well 's Foundation J11 Property Line 1 4! L,, , <br /> LEACHING LINE �No. & Length of lines Tgtal length/size � '�7f�._L� <br /> FILTER BED C Distance to nearest: Well Foundation _ Property.Line` ?�, <br /> _ <br /> SEEPAGE PITS* p D f Depth \` Size—_ _. Number <br /> SUMPS 11. j Distance to nearest: Well _ Foundation Property Line <br /> DISPOSAL PONDS �- _ <br /> ' D t ' , <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, andl�r <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 workman's compensation laws of California." Contractor'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." j i <br /> The applicant must call for al requir i specti ns. Complete drawing on n�everride. <br /> Signed <br /> Title:-� "' 1 - Date: A <br /> FOR DEPARTMENT USE ONLY (� <br /> Area <br /> Application Accepted y Date! r�C <br /> Pit or Grout Inspection by ���fDate �L Final Inspection by LQnV� Date t� <br /> Additional Comments: <br /> U Stk 466-6781 ❑ Lodi 369-3621 rD Manteca 823-7104 ❑ Tracy 835-6385 - -~ <br /> Applicant - Return all copies to: Enviionmiiytal Health Permit/Services 1601 E_ Hazelton Ave., P.O'Boz Stk.,CA 95201 <br /> FEE AF <br /> NT DUE AMOUNT REMITTED" CK � RECEIVED BY DATE PERMIY NO. <br /> INFO CASH-' <br /> . EM 13-24(REV.1/3:;) o <br /> EH 1426 <br />