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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 A. p 71'� e_1 <br /> i PERMIT-EXPIRES 7-YEAR FROM DATE ISSUED, �' 0 !w s r P_/� t7, <br /> k' a. (Complete in Triplicate) Iq Gv-� Ix) 60 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein desCfibed.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 /> I Local Health District. <br /> Job Address 1 S H 7 M W S q6, City' !�OtY Lot Size PM <br /> Q <br /> Owner's Name 5 _ ✓ ]0d8 Address Phone <br /> I Contractor C X 5 Address 1=0 E. FREMAT sT License No.v75'S-6Z/3 Phone A� <br /> TYPE OF WELL PU NEW WELL 171WELL REPLACEMENT ❑ DESTRUCT" <br /> PUMP,INSTALLATION 9 SYSTEM REPAIR El OTHER 10 <br /> -.. DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES .- DISPOSAL.FLD. = �.===QROP­LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .- <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I 2 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> E <br /> ❑ Public ❑ Other 171 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _.. Approx. Depth ❑ Eastern _. Surface Seal Installed by " <br /> Repair Work Done ❑ Type of Pump 13 — H.P. State Work Done e k p cxTr U <br /> MP <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depthi. Filler Material {Below 501 w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is c} <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Capacity. No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth Size Number 1 <br /> °-SUMPS— —' ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 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 /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> fes. .. -°7 <br /> Signed Title: Date: <br /> 7 FO EPARTMENT USE ONLY <br /> Application Accepted y Date �Z Area_ Z <br /> Pit or Grout Inspect) y Date Final Inspection by Date ' <br /> 3 <br /> Additional Comments: <br /> ❑'Stk 466.6761 ❑ Lodi" 369-3621 ElManteca 823-7104 ElTracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> h is <br /> FEE AMOUNT DUE AMOUNT REMITTED 7 CASH RECEIVED BY GATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.1/8 51 <br /> 7. <br /> EH 1428 - - 1,-as bd <br />