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j 3u- al�flPAl <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT 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 t2iCity 2Lot Size �.PM <br /> ~ <br /> Owner's Name <br /> .�3" Address Phone <br /> Contractors Name u�a License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'S <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES 7-:F -- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J40 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial , 13 Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> LlPublic ❑ Other C] Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation w- -2,IjLApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _-�— H.P. State Work Done <br /> Well Destruction ❑ Well Diameter _ ___ Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E3--,REPAIR/ADDITION � DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> = available within 200 feet.) <br /> S " <br /> Installation will serve: Residence--)6► 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 ❑ Type/Mfg Capacity No. Compartments ,1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �7 <br /> Distance to nearest: -alVell Foundation Property Line <br /> i <br /> LEACHING LINE g No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 2V70 f Foundation /D O Property Line rO <br /> SEEPAGE PITS Depth Size_—.3 X - Number <br /> SUMPS ' A Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify thatahave 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."Contractors 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 appiica t must call for all required inspect; S. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FO DEPARTMENT USE ONLY t <br /> Application Accepted by w Date V9Area 0 L30 <br /> jrrrti Date <br /> Pit or Grout Inspection by <br /> k.. ate Final Inspection by <br /> Additional Comments: <br /> ElStk '466-6781 ❑ Lodi 369-3621 ❑-Manteca 823-7104 ElTracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> CAgR <br /> EH 3-24 ,ori Ile-�a ` ,oa ` 7J <br /> EH 14-28 <br />