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L 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) <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 /> ,3 <br /> Job Address <br /> + City .Lot Size PM <br /> I Owner's Name, 7 C <br /> t Address � L:r e s �G <br /> �7 Phone A - 4J <br /> Contractor Address ` �z <br /> TYPE OF WELL/PUMP; NEW WELL ❑ License No. Phone <br /> WELL REPLACEMENT D DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES <br /> DISPOSAL Fi D. -PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br />' ❑ Domestic/Private <br /> -i Gravel Pack Dia. of.Well Casing <br /> e ❑ Tracy Type of Casing <br /> 1-1 Public n Other Specifications - <br /> n Delta Depth of Grout Seal ' <br /> ! I Irrigation' Type of Grout <br /> —.Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair�Work bone ❑ • Type of Pump H P <br /> Well Destruction Q Wel! Diameter Sealing Material flap 50') State Work Done ' <br /> " I Depth Filler Material (Below 501) <br /> EW INSTALLATION 1.1 REPAIR/ADDITION 1 <br /> lV <br /> TYPE OF SEPTIC WORK; N .1 DESTRUCTION (No septic system permitted if public sewer is e <br /> Installation will serve;,.;Residence_W .,,Commercial___Other vailable within 200 feet.) <br /> — <br /> Number of living units: Number of bedrooms 1-14 <br /> Character of soil to a depth of 3 feet: } <br /> SEPTIC TANK r - ❑ Type/MfWater table depth <br /> Type/Mfg.. a ' <br /> _ PKG. TREATMENT PLT. F1Capacity i No. Gompartments <br /> Method of Disposal <br /> Y Distance to nearest:' Foundation Well r+l f <br /> x - *. Property-Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> ❑ _ <br /> FILTER BED, �`-_ - - ,. s._� Total length/size #" <br /> Distance to nearest: Wel! <br /> ~Foundation Property Line <br /> SEEPAGE PITS <br /> I I Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ _ Property Line t f <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. <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'hirind or sub-contracting signature <br /> certifie's the following: '.'I certify that in he performance of the work for which this permit is issuedI shall employ <br /> tion laws of Californi , p y persons subject to workman's compensa- <br /> The applicant mus II for all re ed inspections. Complete drawing on reverse side. <br /> Signed X A . <br /> Title: <br /> I _(„� '��W _ <br /> �`Date <br /> FOR DEPARTMENT USE ONLY r <br /> d <br /> Application Accepted by _ f <br /> Date Area <br /> Pit or Grout Inspec o y bate <br /> Final Inspection by Date�� t <br /> Additional Comments: � � Q 2 3 <br /> ❑ Stk 466-6781 ❑ Lodi 369 621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 20%, Stk., CA 95201 <br /> FEE AMOUNT DUE CK <br /> INFO AMOUNT REMITTED RECEIVED BY <br /> DATE PERMIT'NO, <br /> ♦ EH 13-24(REV.tiHsY <br /> EH 14-28 <br />