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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 FROM DATE ISSUED <br /> Ile (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 /> n 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 /> made i <br /> Local Health District. <br /> P : �bf <br /> fit/ L� �/1�{�E' 7' � City �" a Lot Size PM <br /> Job Address d <br /> �p 'rye V[.o��77� Phone 3~ j <br /> Owner's Name f '•�� 1FAddress <br /> Address License No. <br /> Phone <br /> Contractor <br /> TYPE OF WELLIPUMP: ._ NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION; <br /> SYSTEM REPAIR ❑ OTHER l J <br /> PUMP INSTALLATION ❑ o <br /> DISTANCE TO NEAREST: SEPTIC TANK r SEWER LINES <br /> DISPOSAL FLD. f PROP. LINE <br /> FOUNDATION� <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA �. <br /> Dia. of Weli <br /> Dia'. of Well Casing <br /> 0 Industrial 0 Open Bottom ❑ Manteca Excavation Specifications <br /> ❑ Domestic/Private 0 Gravel Pack ` e❑ Tracy ..Type of Casing <br /> GF1Delta Depth of Grout Seal Type of Grout <br /> [1 Public (-1 Other _ f _ <br /> I 1 irrigation —..Approx. Depth i 1 Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. ' .- State Work Done <br /> Well Destruction Ll Well Diameter Sealing Material [top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i'1 REPAIRIADDITION i:l DESTRUCTION I I avlailabPerwithin 200 feet.)c system permitted if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Numberlof bedrooms <br /> ! Water table depth <br /> Character of soil to a depth of 3 feet: No, Compartments <br /> SEPTIC TANK' 0 , Type/Mfg t Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 <br /> Distance to nearest: Well Foundation Property Line <br /> •� �- � M .�. V :Tota! length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: <br /> Well Foundation Property Line <br /> SEEPAGE PITS 1-1 Depth r 'y _ Size Number <br /> SUMPS 0 Distance to nearest:+ Well Foundation Property Line <br /> DISPOSAL PONDS - - ❑ <br /> k d that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> Thereby certify that I have prepared this application an <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." - -. <br /> i The applicant must call for all required inspections. Complete drawing on/r�everse side. I;?- d�V E <br /> l J �-�'fir� Title '�I f� Date: <br /> Signed X1�d ' <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted.by Ltk <br /> Date Final Inspection by Date Z71 <br /> Pit or Grout (nspecti n by !A <br /> Additional Comment , <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 CJ Matt eca .823-7104 Ll Tracy 835 6385 <br /> + Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> � kNFl7 <br /> r gq <br /> EH 13-241REy.1/n5) 6 ,7 <br /> EH 14-28 <br />