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APPLICATION FOR PERMIT <br />SAN JOAaUIN 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 <br />Local Health District. <br />Job Address ZaS71 City Lot Size PM <br />Owner's Name Address <br />Contractor's Name <br />License No. oZ S'q -4,G-3 Phone <br />19 <br />• •���r r �mr. Nr—VV WELL u WELL REPLACEMENT ❑ DESTRUCTIONw❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑w <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE { <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />❑ Industrial g <br />❑ Domestic/Private <br />❑ Public ) <br />❑ Irrigation o <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca Dia. of Wall Excavation <br />❑ Gravel Pack <br />Cl Tracy Type of Casing <br />❑ Other <br />❑ Delta Depth of Grout Seal <br />--Approx. Depth <br />❑ Eastern Surface Seal installed by <br />Type of Pump <br />H. P. State Work Done _ <br />Well Diameter <br />Sealing Material ftop 5011 <br />Depth <br />Filler Material (Below 50'1 <br />Dia. of Well Casing I <br />Specifications <br />Type of Grout <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR /ADDITION DESTRUCTION ❑ (No septic system permitted if i <br />t available within 200 feet.) <br />Installation will serve: Residence X Commercial _ :Other <br />I <br />. - <br />Number of livin units: k ' '''+gip`• <br />9 �— Number of bedrooms J� <br />Character of soil to a depth of 3 feet: 4 Water table depth <br />SEPTIC TANK No. Compa <br />esg rtm <br />PKG. TREATMENT PLT. ❑ Method of Disposal <br />Distance to nearest: rWell. a- Foundation Property Line.. <br />wwr , ter Y-"' ".. •--• <br />LEACHING LiNE <br />FILTER BED <br />IW No. & Length of lines / 40, Jr <br />❑ Distance to nearest: Well — <br />sewer is <br />I <br />­.." Total length/size <br />Foundation O° <br />Property Line <br />SEEPAGE PITS Depth !© y Size3 .Number f <br />SUMPS Distance to nearest: Well Foundation 49, — -w <br />DISPOSAL PONDS Properly Line i 111 <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. {-- l <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." Contracto`�s hiring T 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 tion laws of Ca 'fornia.' p y persons subject to workman's compensa- <br />.; <br />The applicant call for require ' spect' ns. gomplete drawing an reverse side. •t i <br />Signed y.7.;`` • C3 <br />Title:Date: <br />OR DEPARTMENT USE -ONLY <br />-•-�- t r I <br />Application Accepted Qater ��67�$;-Q Area <br />Pit or Grout Inspectio yDate 1�� <br />Final Inspectio y Date <br />—Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-.7104 ,❑ Tracy,8355-6385 c, ! <br />Applicant - Return all copies to: Environmental Health Permit/Services •1601' E.' Hazelton Ave., "P.'l). B x'2009, Stk., CA 95201 <br />+ EH 13-24 (REV. <br />EH 14-28 <br />