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- <br /> 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 TYEAR 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 SarilkJoaquin 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 17SQd City Lot Size6 PM <br /> HF: <br /> Owner, W' Address /.� _� Phone <br /> Contract 6_812,L 17=J_ <br /> Address License No3 �� W <br /> Z °� Phnne 0 \ <br /> TYPE OF WELL/PUMP:a NEW WELL 11WELL REPLACEMENT EIDESTRUCTION 1-1 <br /> r =, PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ---DISPOSAL--FLD. --r--.-PROP.LINE <br /> FOUNDATION,f AGRICULTURE WELL = OTHER-WELL_ _ - ;PITS/SUMPS- <br /> ri <br /> INTENDED USE i�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS— <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public ❑pp Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ryl <br /> I I Irrigation .Approx. Depth 1 I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Ma l (Below )- <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION I I REPAIR ADDITIO l DESTRUCTION ( I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: I Number of bedroom If <br /> ' ,;" ! <br /> Character of soil to a depih-of­3-feet:---______ -- - Water table depth Qd <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> ;I Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Vli No. & Length of lines r (otal,length/size 70 X <br /> t FILTER BED ❑' Distance to nearest: Well _ Foundatiori r� • ,Property Line 5' <br /> SEEPAGE PITS I-�I_Depth c2Y Size l�7 * Numbers I <br /> SUMPS ❑l Distance to nearest: Well- Foundation h _T.Property Line <br /> _DISP05AL PONS 17111 _�� <br /> I hereby certify that I have prepared this application and that the work-will-be done-in accordance with SariJoaquin 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'workrrian's.compensation laws of California."Contractdes 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 perso`ns,sct to workman's compensa- <br /> tion laws of California." ill-41 <br /> I The applicant st call for l req "red inspections. Complete drawing on reverse sid <br /> Signed Title: u. Date:U 0 <br /> I aln, <br /> FOR DEPARTMENT USE ONLYA plication Accepted by I`� � �l Date �� '� 7 Ar � L <br /> r II <br /> P or Grout Inspection by_ Date 1 /r Final Inspection by � Date <br /> Additional Comments: <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. Hazelton Ave„ P.O, Box 2009, Stk., CA 95201 <br /> I INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT"NO. <br /> + EH 1124(REV.t/A 5f <br /> ' EH 1426 <br /> IM" <br />