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APPLICATION FOR PERMIT <br /> JG <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT G <br /> 1601 PE. HAZELTON 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 ` / � ' 'l�� i�ef� City Lot Size`0 t �T�/ PM <br /> Owner's Name„ Address ID32- /J Phone <br /> Contractor-, b ya Address 'C7tGL(A License No. q�4 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL T OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public F1 Other F1 Delta Depth of Grout Seal Type of Grout ____ <br /> I I Irrigation __ Approx. Depth I I 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 50') __ 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 4-'DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) S <br /> Installation will serve: idence V Commercial Other <br /> Number of living units: Numberedro ms�_ B�/ <br /> Character of soil to a depth of 3 feet: A e%� Water table depth I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line " <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑/Distance to nearest: Well Foundation Property Line CA <br /> SEEPAGE PITS Pr Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation /6 Property Line_/Q� - <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, ands <br /> rules and regulations of the San Joaquin Local Health Diltrict. <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, 1 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 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 applicant must call for a required inspections. Complete drawing o�revverse side. <br /> Signed X o Title: 5 & <br /> . .r,vey Date: <br /> FOR DEPARTMENT USE ONLY c <br /> Application Accepted by Date': o 56 rea .71 <br /> Pi or Grout Inspection by 'z Fal Inspection b Date <br /> Additional Comments: <br /> / <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a EH14-241REV.t/N5) __7 `. bO K.7 _1.5 <br /> EH 14-28 <br />