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y N <br /> T <br /> APPLICATION FOR PERMIT <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 /> / ft _ <br /> Job Address J ,±/1 C2 , f�� /k.� • a0490A - . AV City Lot Size PM <br /> Owner's Name 7/ Z7 do? Address AZ Phone <br /> Contractor i' dtlress' nse No. Phone SP <br /> TYPE OF WELL/PUMP- - NE ELL.��, _.,..._WELL REPLACEMEN7,13_ ,�,',.�; DESTRUCTION•.O__,_. <br /> PUMP iNSTALLATI N D ` SYSTREPA� ❑ TH��❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 7�" DISPOSAL FLD. PROP-LINE- <br /> s <br /> FOUNDATION °i AGRICULTURE WELL OTHER WELL. �S- PITS/SUMPS <br /> • INTENDED USE TYPg OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS t� <br />' ❑ Ind u trial pen Bottom ❑Manteca 4 Dia.--f,,Well Excavation , Dia. of Well Casing <br /> t j <br /> omesticlPnirate ❑ Gravel Pack ❑ Tracy Type of CasingF. T Specifications <br /> M Public I-1 Other ❑ Delta t Depth of Grout Seal Type of€Grout <br /> A�r+ l` 1 <br /> ] Irrigation J *To Approx. Depth l I Eastern Surf Seal Installed by <br /> Repair Work Done C Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameterra r 'Sealing Material (top 50a <br /> Depth'_ 0)V,A­ Filler Materjal (Below 50'),L <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION l 1 (No septic'system.perm(tted if public sewer(s <br /> t available within 200 A2et.) <br /> Installation}will serve.- Residence— Commercial_ Other <br /> Number ofliving units: Number of bedrooms F [ ` <br /> Character of soil to a depth of 3 feet: Water table depth: <br /> SEPTIC TANK""`"""""'—Cl_'Type/Mfg Capacity No. Compartments-— —�-� <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well �_ Foundation Property Line r <br /> LEACHING LINE 0 No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; <br /> t <br /> SEEPAGE PITS 11 Depth ___ „__.SizeNumber __ <br /> SUMPS LI Distance to nearest: Well I 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, an <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 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> E <br /> The applicant m call for all re uir d inspections. Complete drawing on re rse side. <br /> Signed X -14 Title:. � Date:V7 _ <br /> FOR DEPARTMENT USE ONLY ` <br /> Application Accepted by c Date —(!rffArea f 0 <br /> - f <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 L163 <br /> Tracy 835- 85 <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 CK I CASH RECEIVED BY i DATE PERMIT-NO.e <br /> E 1-28 <br /> + H 1IpEV.tiHSY ' tQ� /� SW—A3 <br /> }3S 1 <br /> . <br /> EH 3-24 <br />