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Con STLIe_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 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 /> r� <br /> Job Address W 4015 City. c enle1S Lot Size PM <br /> Owner's Name e _ lLli�_h Address Phone 1 <br /> Contractor l~ SLicense No. <br /> 3fT 0Dl y__Phone_ — 2 <br /> i TYPE OF WELL/PUMP: NEW WELL P` WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1/ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK dd SEWER LINES DISPOSAL FtD-302 �PROP. LINE <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �z ` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private L'3'r�ravel Pack ❑ Tracy Type of Casing 6" Specifications <br /> 1-1 Public (7 Other ❑ Delta Depth of Grout Seal �i_.-._...-� Type of Grout_sack <br /> I I Irrigation 3392_Approx. Depth l l Eastern Surface Seal Installed by- 7 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <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 /> SEPTIC TANK EJ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> ' FILTER BED ❑ Distance to nearest ' Well Foundation Property Line <br /> 4 <br /> SEEPAGE PITS 11 Depth Size Number <br /> .t SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 /> Signed L ", Title: Date: <br /> ��'""" 0- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ttf <br /> Pit or Grout Inspection by Date p� Final Inspection by a �� G,�/f <br /> f1-1As Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 O Lodi 369-3621 C] 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 /> F <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED c RECEIVED BY `DATE J PERMIT NO. <br /> +.EH13-24fpH <br /> EV.�/ sl /D� 1 V� •� rJ� 1 1 Cl <br /> /f P5 <br /> EH 14.213 <br /> 1;. <br />