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v <br /> F <br /> ( APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 9 ` <br /> C Job Address City Lot Siis PM <br /> V <br /> I Phone � 0 <br /> Owner's Nam Address rS�/'h � _ - _ <br /> �` 466W License Nr��-3_2 S Phone G� <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ v WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '" DISPOSAL —PROP—LIN-E <br /> FOUNDATION AGRICULTURE ER WELL f PITS/SUMPS _r _ <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ ca Dia. of Well Excavation ia. of Well Casing <br /> Type of Casing Apecifications <br /> El Domestic/Private El Gravel Gravel P ❑ Tracy YP 9 , <br /> r l C'1 Public .,x-17 O " ` "=• F1Delta s Depth of Grout Seal i 1 Type of Grout <br /> I I Irrigatione _..Approxi-Depth I I,Eastern Surface Seal Installed by <br /> Repair V1lork l ❑ Type of Pump H:P t - State-Work.Done— <br /> Well D uction ❑ Well Diameter Sealing'Matedal (top 5019' ` <br /> Depth Filler Materiel (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION`LI DESTRUCTION € I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Ae Commercial_ Other <br /> Number of living units: . Number of bedrooms g <br /> Character of soil to a depth of 3 feet: 4.bckP- t t _Water table depth <br /> II ❑ Type/Mfg CapacitY Nd.'CompartmentsSEPTIC TANK <br /> PKG. TREATMENT PLT. 11 _ Methodf ofDisposal , <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE No. fat Length of lines _ /� <oo Total length/size-7 <br /> FILTER BED 0 Distance to nearest: Well ;Foundation Property Line' <br /> • � � I <br /> SEEPAGE PITS I 1 Depth Size mbar. <br /> if <br /> SUMPS L-1 Distance to nearest: Well - Foundation 192 - Property Line 6 <br /> DISPOSAL PONDS ❑ 1 <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. I I <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."Contractof'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." W <br /> r The applicant m call far I requ d inspections. Complete drawing on reverse side. 4 <br /> i <br /> Signed Title; Date, --- <br /> �^- \`XOR'D ARTMENT USE ONLY <br /> Application Accepted by L } —.Date Area, <br /> Pit or Grout Inspection by Date Final Inspection by _ Date <br /> _ F <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 835-6385 <br /> A plicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH 13-241REV.iin51 ♦y� ' �� �_ y .� �� �I. (} <br /> EH 14-26 /V <br />