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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 /> Job Address -a 3'TS'Be7 City rYArt Lot Size `/' 3'es PM <br /> Owner's Name 45,4 ry 4 4 L Address 'A;1 Phone Ow--e Y-No <br /> Contractor's Name Ore /YT I w 90 f0� License No. ��y- 0�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> j PUMP INSTOL„#LATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout 1J+ <br /> ❑ Irrigation 1---Approx. Depth r Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter I Sealing Material (top 501 <br /> s I <br /> Depth j Filler Material f8elow 501 <br /> TYPE OF SEPTIC WORK: !NEW INSTALLATION ❑f4REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is f <br /> available within 200 feet.) <br /> Installation will serve: Residence Z— Commercial T­ ther <br /> Nurr&-r of living-un 7 Number of bedrooms <br /> Character of soil to a depth of 3 feet: rA� 4,0.4,v Water table depth l <br /> SEPTIC TANK k1 Type/Mfg d Ci'�1T Capacity 01W No. Compartments 3 <br /> PKG. TREATMENT PLT. ❑. Method of Disposal <br /> l + Distance to nearest: Well 64 Foundation /4• Property Line <br /> LEACHING LINE ❑� o. & Length of lubes Total length/size <br /> FILTER BED �Di " ncd to near¢qtf-- Well Foundation xs" Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line t <br /> DISPOSAL PONDS 1 ❑ `'� Air? ;. k j Z <br /> I hereby certify that I have prepared this applica errand that the work will be done in accordance with San Joaquin county ordinances,%tate laws, and <br /> rules and regulations of the San Joaquin La££al--Health District. �^ <br /> Home owner or licensed agent's signature cehifies the following: "I certify that in the pe forr?ahce 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 comoensation laws of California."Contractoes hiring or sub-contracting signature <br /> certifier the following: "1 certify that in the perforJnarir .of'the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The applicant mug-call for all required inspectio s. Complete drawing on reverse side. <br /> Signed € Title: Date: <br /> r FO EPARTMENT USE ONLY <br /> i <br /> Application Accepted by IDate ` . Area. 49 <br /> r -� � <br /> Pit orIGrout Inspection by -Dates-a Final Inspection by�ot;M .E Date <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83rr6385 <br /> Applicant- Return all copies t¢: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO /MOUNT DUE AMOUNT-REMITTED CASHRECEIVED 9Y DATE PERMIT"NO. <br /> �/� �� <br /> + EH 13-24(REV.10/631 "l9 �S � <br /> EH 1426 i <br />