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APPLICATION FOR PERMIT <br /> 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 I <br /> • " made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump a the Rules and Regulations of the San Joaquin 1 <br /> Local Health District.. <br /> City of Size r +� lt+o• PM �.� <br /> Job Address y� <br />' 00 <br /> Address ' Phone G <br /> Owner's Name — — °t `t <br /> `ry �� Address T7- T ._-_ -�.-__- icense No. •Phone <br /> Contractor _ ' <br /> TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT ❑, DESTRUCTION ❑ o <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 71OTHER ❑ � <br /> E. c1 J. .SEWER LINES DISPOSACFLD. . PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ __ <br /> FOUNDATION AGRICULTURE WELL f OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WtEL 'PROBLEM AREA +CONSTRUCTION SPECIFICATIONS <br /> ► ❑ Open Bottom ❑ Manteca f Dia. of Well Excavation Dia. of Well Casing <br /> 4.0:Industrial tt <br /> t Type of Casing •.:Specifications <br /> CSfaomestic/Private ❑ Gravel Pack 0-Tracy <br /> h [ Delta Depth of Grout Seal .;Type of Grout — <br /> l ("I Public rt f7'Other <br /> I I Irrigation —_Approx, Depth I 1 Eastern Surface Seal Installed by w <br /> rH P_-: State Work Done <br /> i ,Repair Work Done L) Type of Pump _ ^ <br /> W Sealing Material (to 50'1 <br /> ' Well Destruction ❑ Well Diameter -_ g p <br /> Depths •� • <br /> .3 -.Filler Material {Below 50'1 f� L/1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i HLf AIR/ADDITION ! I DESTRUCTION I I INo septic system permitted if public sewer is <br /> r• available within 200 teet.l <br /> Installation will serve: R ence X_ Commercial Other • <br /> Number of living units: Number of bedrooms' r <br /> Character of soil to a depth of 3 feet: S Water,table depth <br /> Capacity No. Compartments <br /> SEPTIC TANK •CST Type/Mfg ¢ <br /> PKG.4TREATMENT PLT:"❑ * t �r • t / Method of Dispa�sal <br /> g. D / <br /> �- Distance to nearest: Well: .__ F&n'dation Property Line <br /> LEACHING LINE * ❑ No. & Length of lines Total length/size <br /> FILTER BED LI `..- c- to nearest:' Well Foundation 1�_ Property Line_ r <br /> 1 <br /> SEEPAGE PITS I+i�Depth Size Number <br /> SUMPS Ll 4.0istance to nearest: Well � �Foundation -`Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have'prepared this application and that the work will he done in accordance with San Joaquin county ordinances, state laws, and_ <br /> rules and regulations of the SanUoaquin Local Health District. <br /> +� Home owner or licensed agent's signature certifies the following: "I certify that- the performance of the Cwork-fortract 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."Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the perfovmance of•fhe work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> ' The applican t call for all re fired inspection . Complete drawing on reverse side. <br /> — bate: <br /> Signed X 41 <br /> r = DEPARTMENT USE-ONLY <br /> Application Accepted by Date l Area <br /> b)or Grout Inspection by <br /> Date - Final Inspection b Da <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621j-=•�­❑ 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 <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ..EH 13-24(REV.t/H 5) <br /> It, <br /> EH 14-25 - f� <br />