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J ] APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRfCT <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. <br /> Job Address ! G� i ;iLlylC> ._,,._.. Cit /G` c-'`t-/Lot SizeC?1­7 PM <br /> / <br /> Owner's Name <br /> }}/ �� L_ _/C.� Address n Phone <br /> Contractor ^ � ���'� Address ' t ? ' License No: Phone_ <br /> TYPE OF WELL/PUMP: EW 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 OTHER WELL_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> LI <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 Public -1 Other ❑ Delta Depth of Grout Seal _ Type of Grout <br /> I Inigation _-_ Approx. Depth I I Eastern Surface Seal Installed <br /> Repair Work Done {J Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: J Number of bedrooms 5 <br /> Character of soil to a depth of 3 feet: Water table depth _ <br /> SEPTIC TANK ❑ Type/Mfg 7 _� CapacityNo. Compartments <br /> PKG. TREATMENT PLT. L) Method of Disposal <br /> Distance to nearest: Well -0 foundation /_'Property Line //0 <br /> LEACHING LINE ❑ No. & Length of lines 7 Total length/size C� <br /> FILTER BED ❑ Distance to nearest: WeII�, Foundation ��: �� Property Line <br /> SEEPAGE PITS -A-- Depth Size % Nymber . <br /> SUMPS LI Distance to nearest: Well ZT: e) , Foundation __ C1 - Property Line <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, 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." 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 l]r ust call f all req inspections. Complete drawing on reverse side. <br /> Signed X �! - 7 � <br /> - Title: Date: _/CC <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 4 ate— Area <br /> Data L cT `- <br /> �e - <br /> Pit or Grout Inspection bye Date /��!c <br /> -, Final Inspection by Date :".G�5 <br /> Additional Comments: <br /> El 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 CK RECEIVED BY <br /> INFO CASH DATE PERMIT'NO. <br /> !) + <br /> + EH13-24(REV.5%R 5) <br /> EH 1428 {.: 1' ! f 1 ��' �'� ,�`-7 �� �t� '��✓:� <br />