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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) f <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 �,V-h)&b _ City Lot Size PM <br /> Owner's Name _t4 K L — _ Address !E,7 fftM Phone lI <br /> 1 <br /> Contractor L CAddress 5 0 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW-WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ 3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ , <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL . OTHER WELL PITS/SUMPS <br /> INTENDED USE ^TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial I <br /> l IA,❑,Open Bottom 71 Manteca Dia. of Well Excavation Dia. of Well Casing - <br /> Ll Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing Specifications , <br /> M Public f [ LiOtfier fa Delta Depth of Grout Seal Type of Grout A <br /> I IIrrigation ­Approx. Depth LI Eastern Surface Seal Installed by 3� <br /> Repair Work Done L7 Type of Pump __LL___ __H.P_ State Work Done t � <br /> 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 z <br /> f Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I ]-DESTRUCTION I septic system permitted if public sewer is <br /> 1, r available within 200 feet.) t <br /> Installation will serve: Residence Comme ih Other + ; j <br /> Number of living units: Number'of bedrooms # €! ] <br /> Character of soil to a depth of 3 feet: f Water table depth JI <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ y Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ,.. - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Aistance to nearest: Well Foundation Property Line <br /> t <br /> r . <br /> SEEPAGE PITS I 1 Depth Size f Number f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line Y <br /> DISPOSAL PONDS ❑ <br /> P ~ <br /> 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, and I <br /> rules and regulations of the San Joaquin Local Health District. s <br /> Home owner or licensed agent's signature certifies the following: 1 certify that in the performance of the work for which thiipermit is issued, I shall not <br /> eryloYany person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature 1 <br /> ce he 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 o alifornia." L.. t <br /> Th applica m ca for II r uired i s t omplete drawing o e ers } <br /> , 1� - -2 <br /> Signed , 'Title s Q Date:1 / 2 <br /> f <br /> , .FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _ \Area y <br /> Pit or Grout Inspection by Date. 1!F__inal Inspectipp by `–�`– �� Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED %CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24[REV.i/H 5) ler G O <br /> Eli 11-28- — J - - � <br />