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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 FPOM 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. s <br /> S'?�o'[��`S. C�tl-[ .r-t r4=a_ �-.Q {. ,/�/��i� �t�iC1: .Z..S3--2,7t? <br /> � L <br /> [� I11 U 10-D DR E_5-. I-,s KF7 <br /> Job Address 4:'0 Li T H' E IJP OF C HR!SCity Lot Size PM <br /> r <br /> Owner's Nam Address Ae Phone �„ <br /> Ila <br /> 1 ContractorAddress12 F— a1LaE STLicense too. S1��51� Phone F!eq1 <br /> _TYPE OF WEL ' El REPLACEMENT ❑ <br /> PUMPEW WELL W <br /> DESTRUCTION LJTHE <br /> 7lON <br /> " " ` ""Pl1MP INSTACLATI I "- v - SYSTEM-REPAIR ❑ '""" <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 ❑ Open Bottorb ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I,$Public ❑..Other CI Delta Depth of Grout Seal T <br /> k � ype of Grout _ <br /> t I I Irrigation ­Approx. Depth I 1 Eastern Surface Seal Installed by nn <br /> Repair Work Done ❑ Type of Pump o H.P. ' - State Work Done 1' <br /> f Well Destruction ❑ Well Diameter Seating Material {top 50'1 <br /> M _ <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is r"1 <br /> available within 200 feet.) <br /> Installation i erve: Residence— Commercial— Other <br /> Number of living units. Number of bedrooms r <br /> Character of soil to a depth of 3 fee . Water table depth <br /> ' SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. EIIMethod of Disposal <br /> Distance to nearest: Well <br /> Foun Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal a size <br /> FILTER BED. ❑ Distance to nearest: .Well <br /> Foundation property I , <br /> SEEPAGE-PITS- 41—Depth = _ - Size .Number- <br /> SUMPS LIDistanceProperty Line <br /> Distance to nearest: Well <br /> DISPOSAL PONDS ❑ r <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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I cartify_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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> _ Title: Date: ���, <br /> FOR PARTMENT USE ONLY r <br /> Application Accepted by Date 7 '& IF <br /> ' Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 1) Lodi 369-3621 ❑ Manteca 823-7104 11 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.B xo 2009, tS k., CA V520V I <br /> FEE AMOUNT DUE AMOUNT REMITTEb <br /> INFO CASH RECEIVED BY DATE PERMIT'Np, <br /> + EH 1324{f1EV.1/9 51 <br /> EH to-zs <br />