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ark,' .;yAPPLICATION FOR PERMIT �, <br /> p SAN JOAQUIN LOCAL HEALTH DISTRICT { <br /> 'y 1601 E. HAZELTON AVE., STOCKTON, CA ~� <br /> r ;F Telephone {209) 466-6781 <br /> t' ! 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 /> il. <br /> J <br /> Job Address " Cityr� Lot Size PM <br /> I Owner's Name ^'� �GAddress ` Phone ` <br /> I �` <br /> Contractors l Address rr _ License No. -1 3-1 Phone <br /> } TYPE OF WELL/PUMP:IE b&7V WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION,. .. . .AGRICULTUR_E WELL --OTHER WELL. _P_ITSI.SUMP_S__ <br /> [ INTENDED USE p TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1 ❑ Industrial 1-1 Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t ❑ Domestic/Private I` ❑'Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ! ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> 1 1 Irrigation Approx. Depth 1 ) Eastern Surface Seal Installed by \ <br /> i <br /> Repair Work Done ❑ i Type of Pump l H,P. State Work Done_ <br /> Well Destruction O .I Well Diameter Sealing Material (top 501 <br /> $ Depth Filler Material (Below 501 <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION . , DESTRUCTION l I (No septic system permitted if public sewer is <br /> iI available within 200 feet.) <br /> Installation will serve: i Residence_ Commercial Other r <br /> Number of living units: Number ofb drooms <br /> ` Character of soil to a depth of 3 feet: �)L��--ti ,Water table depth Vd j <br /> SEPTIC TANK ❑ Type/Mfg �- Capacity / !Po. Compartments <br /> PKG. TREATMENT PLT. El I. x. f�A AMethod of Disposal <br /> E? ii Distance to nearest: Well_ Foundation i P.ro/.'erty Line <br /> LEACHING LINE II❑ ij.No. & Length of lines -+ Total,-length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation JJ i Property Line <br /> t SEEPAGE PITS I ] Depth _ Size__ f7r x l� X S f Number <br /> SUMPS Distance to nearest: Well 9 _ Foundation _f G i Property Line /d <br /> I . <br /> DISPOSAL PONDS d❑ <br /> 1 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 Jojquih Local He3lth-DiMr'ict." L ( r <br /> f Home owner or licensed`agent's s jnature certifies t!iJ following: "1 certify that"in the performance of th&work for which this permit is issued; I shall not <br /> r employ any person in such manner asrtoAE!cLp ne subject to workman's compensation I ws of California"".('4tractor's hiring or sub-contracting signature <br /> t certifies the following: "I certify that in the performance of the work for which tFiis pi#rrrrt is'issued,-k shall employ persons subject to workman's compensa- <br /> tion laws of California."' s <br /> I The applicant m tail forrequired inspections. Complete drawing OR reverse side. <br /> A " 1Z�eej:�* <br /> Signed X ,Title: 1 Data: <br /> --- <br /> I� FOR DEPARTMENT USE ONLY �- <br /> Application Accepted by - - Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 11-977kT <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 1 <br /> n <br /> r I':FEEj <br /> INFO AMOUNT DUE AMODUN�T..REEMITTED C SH CK 4 RECEIVED 6Y DATE PERMIT'NO. <br /> a.EH 13-241REV.tiH5) f � p �4�'� } A ^�O <br /> EH 14-28 VV <br />