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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 <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. /� nh <br /> Job Address 2_01 k Woo-0�C 51*0e:. L,..,. City � Lot Size PM <br /> CAJW0(9itt 01a GQ.LF CoV6,r" Ctud <br /> S.i <br /> Owner's Name Address ._. _ Phone-8 <br /> �S Se� <br /> Contractoeti'14 r....AAAE _Address 1 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL'S _ REPLA• ENT ❑ ++ ESZRIC ON ❑ <br /> PUMP INSTALLATION '�'"SYSTMPAl <br /> 0 -RE. <br /> DISTANCE TO NEAREST: SEPTIC TANK~,._•— -'SEWER LINES DISPOSAL FLD.� PROP. LINE 7 <br /> ATION /AGRICULTURE WELL OTHER WELLL^ PITS/SUMPS _.. <br /> INTENDED US TYPE OF WELL PROBLEI1 AREA CONSTRUCTION SPECIFICATIONS <br /> -. <br /> u ria) ❑ Open Bottom ❑ Manteca, Dia. of Well Excavation Dia. of Well Casing I 1b <br /> e �{Gravel Pack C1 Tracy Type of Casing d* Specifications <br /> r' a Ic r=l Other Cl Delta Depth of Grout Seal ,# ♦ Type of Grout�tllte M't` <br /> X rf riyatio J 3 00_Approx. Depth l I Eastern Surface Seal Installed by e. <br /> _,,_/hepair Work Done ❑ Type of Pump H.P, State Work Done_ <br /> We11.Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> DepthFille(Materiai (Below 50') <br />► TYPE OF SEPTIC WORK; NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br />,�► available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Othe <br /> Number of living units: Number of bedrooms f <br /> r' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ti SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:❑ Method of Disposal <br /> r Distance to nearest: Well FoundationProperty Line <br /> r ,1 <br /> --d-LEACHING LINE 0 No- & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Linef. <br /> SEEPAGE PITS I ] Depth Size + ` NumBer. <br /> .SUMPS Ll Distance to nearest: Well' Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> Jhereby 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 /> ules and regulations of the.San Joaquin Local Health District. ti <br /> iome 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 noir <br /> +mploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur' <br /> ertifies 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 /> on laws of California." q , <br /> he applicannttmust call for all required inspections. Complete drawing on•ieverse side. <br /> ,he <br /> X_It G Title: n Date: <br /> i <br /> FOR DEPARTMENT USE ONLY. <br /> .)plication Accepted by Date Area/ <br /> or rou Inspection by Date Final Inspection by <br /> ditional Comments: $� Cyt ' vs- / <br /> 5tk 466-6781 ❑ Lodi 09-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 r <br /> fACant - 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 <br /> i INFO ,CASH RECE1VEb BY DATE PERMIT'NO. <br /> IEv,1/H 51 5relf- " e <br /> _ <br /> 37 <br />