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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 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address G+ City,�OC --) Lot Size © PM <br /> Owner's Name /g/i .ti5/a Address Phone f e <br /> r� nn ,� • � ,9 <br /> Contractor Q_ r%�r'I e°�dii%//�.0 dtlress 2�! ' a"d !l License No.��-'OYZ/ Phone�"� �y"�s <br /> TYPE OF WELL/PUMP: NEW ELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ <br /> E P0MP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER ❑ <br />{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION ^AGRICULTURE WELL OTHER WELL PITS/SUMPS'--. (� <br /> -1 <br /> „;. �j <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 171; pen Bottom ❑ Manteca Dia. of Well Excavation /L Dia. of Well Casing ' <br /> Z Domestic/Private ravel Pack ❑ Tracy Type of Casing P V, Specifications <br /> ('l Public (- ,Other [=l Delta Depth of Grout Seal Typo of Grout <br /> �slc <br /> I I Irrigation Z ..Approx. Depth I i Eastern Surface Seal Installed by T1 i <br /> ll <br /> i <br /> E Repair Work Done ❑ Type of Pump -5116 H.P. 6 State Work Done_ <br /> Well Destruction ❑ Well Diameter. 4” Sealing Material (top 501 <br /> C)4th ?.Y22 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is , <br /> Iavailable 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 /> SEPTIC TANK ❑ 1,Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> iIDistance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ i rNo. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation Property Line <br /> t SEEPAGE PITS I l Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have plepared this application and that the work will be done in accordance with San Joaquin county ordinances, siate laws, and <br /> rules and regulations of.the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "Lcertify 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 became 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_ c <br /> tion laws ofompensa- <br /> CEa.-. r <br /> The applicantr all re urred inspections. Complete drawing on revArse side. <br /> Signed X Title: w�O� Date:Z - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byC11. IV, Date "3 ` - Area <br />` Pit or ra Inspection by Date -�--� Final Inspection by <br /> I . <br /> I Additional Comments: II <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 /> s <br /> FEE <br /> K 4 <br /> INFO AMOUNT DUE AMOUNT REMITTED GSH RECEIVED BY DATE PERMIT'NO. <br /> I 1.EH 13.24(REV.1114 5) ��� lOs 96 <br /> EH 14-26 .. of <br />