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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 7 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 i <br /> Local Health District. <br /> r". <br /> Job Address 2 City Lot Size <br /> PM <br /> Owner's Na Address I I!!�� �-y�r Phone <br /> llll <br /> -Contractor US�_ Addresspouomr . e No' ' Phone <br /> TYPE OF LL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. . PROP. LINE <br /> FOUNDATION AGRICULTURE WELL f OTHER WELL PITSISUMPS 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> t`❑ Public ❑ Other �a, ❑ Delta Depth of Grout Seal Type of Grout 1 + <br /> ❑ Irrigation --Approx. Depth* ❑ Eastern Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pump, H.P.. -State Work.Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 f" <br /> Depth t Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION ❑ DEST UCTION ❑ (No septic sy%em,permitted,if public sewer is <br /> - available within 200 feet.)'- <br /> Installation will serve: Residence_° —_Co ercial Other l <br /> Number of living units: Number of drooms <br /> Character of soil to a depth of 3 feet: Water table.depth 0 <br /> SEPTIC TANK �T Type/Mfg IfZt4 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I I Method of Disposal <br />'a Distance to nearest: Well fy77 Foundation ._ Property Line <br /> LEACHING LINE No. & Length of lines <br /> g � 19 � T'otail length/size � <br /> I FILTER BED ❑ Distance to nearest: Well 6-t� ! Foundation_._� Property Line <br /> Size <br /> Depth SEEPAGE PITS IX De t <br /> _ P _ Number <br /> SUMPS ❑ Distance to nearest: wellf�f?! Foundation 7D t Propetty Line =2 <br /> DISPOSAL PONDS ❑ �` <br /> r <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: "1 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."Contractors 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 Cal'ornia." , <br /> The applican m st cal d inspections. Complete drawing on reverse side. <br /> Signed _ i Title:—.� Date: <br /> FOR DEPARTMENT USE ONLY <br /> lication Accepted by i Date t <br /> �.P�t�6r Grout Inspection by Qv . J c Da .ta� -Itl' Final Inspection by Date �`�l <br /> Z.. . a <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13.24 fREV.w/s5Y ­A0 4�D CO <br /> .- EH 1428 Z� sr O <br />