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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t 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 /> / <br /> Job Address S 2 C/�- <br /> City Lot Size PM <br /> Owner's Name��--=��-- Atldres �3 o Z <br /> Phone <br /> Contract Address f, 7 y2 <br /> License No. Phone 31�b'S—/ S— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El <br /> LINES DISPOSAL FLD• PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑Irrigation -A Type of Grout <br /> --Approx. Depth El Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter _ <br /> Sealing Material (top 50'1 <br /> Depth r Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence4-1CommercialOther available within 200 feet.) <br /> —� <br /> Number of living units: Number of be ooms J <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK �/ Water table depth d <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE L�No.& Length of lines q(f D <br /> FILTER BED O, Total length/size X <br /> ❑ Distance to nearest: Well Foundation <br /> - � -�_ Property Line c� <br /> SEEPAGE PITS /�l/Depth Size r( <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well /0 Foundation LQ Pro <br /> DISPOSAL PONDS ❑ Property Line .� <br /> 1 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 m t call for all re 'red . spections. Complete drawing on rev r sib <br /> Signed Title:- SP <br /> ` Date: <br /> / FOR DEPA,�OENT USE ONLY <br /> Application Accepted by / Date <br /> OZ Area <br /> .or Grout Inspection by ate- :�V -7- inal Inspection byDate �.�?, <br /> Additional Comments: <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 gMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PER NO. <br /> + EH 13.24(REV.1/85) <br /> EH 14-28 <br />