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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete i Tliite) <br /> Application is heteby made to the San Joaquin Local Health District for a j-&--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 Wealth District. <br /> �[/ <br /> Job Address v J2 Ci Lot Siz PM <br /> Al Ai ���' <br /> Owner's Narn Address Phone <br /> iax <br /> • ��� J_� <br /> U 767 �License No Phone {o' <br /> Contrac Address t <br /> TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT-a.; DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPd1A 0 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 /> E) Industrial ❑ Open Bottom ❑ Manteca Dia. of V444xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 0 Tracy Type-of Easing Specifications <br /> I'1 Public .Other n Delta. Depth of Grout Seal Type of Grout _. <br /> I I Irrigation � ._Approx. Depth 11 Eastern Surfacq Seal Installed by <br /> Repair Work Done ❑ •T'ype of Pump H.P. ,�j State Work Done d <br /> Well Destruction ❑ 'V sill Diameter Sealing Material(top..50') <br /> Depth ,__ . r Material (64kivv 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I RFi'AI ADDITION <br /> DESTRUCTION I I (No septic system permitted if public sewer is <br /> a"vail$ble within 200 feet.) <br /> Installation will serve: R once Commercial Other ` ' r <br /> Nu 61 living units: Number of roam <br /> "�' ; '. Water table depth <br /> Character of:soil to a depth of 3 feet:. '"�� <br /> SEPTIC TANK 0 TypelMfg Capacity fVo,,CompartAnat <br /> PKG. TREATMENT PLT.© Method of Disprosa(' - <br /> DistaP6 t¢nearest: Well Foundation Propertylne <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel,I Foundation Property Line <br /> JW <br /> N <br /> SEEPAGE PITS Depth _ :-Size.. dumber <br /> SUMPS {(l.' Distance to nearest: Well Foundation;ID Property Line <br /> DISPOSAL PONDS <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 Di§trict. <br /> Home owner or licensed agent's[signature conitiea-the fellowing: "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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." "® <br /> The applicant muN for all r ed' spections. Corn'Ogte drawing on reve si <br /> Z0 <br /> -� <br />" <br /> Signed Title: • Date . <br /> i IR DEPARTMENT USE ONLY ?� Z <br /> Application Accepted by - - - Date sem ✓ Area_ <br /> 4 ... .) ___ __. .... i _ Final Inspection by '"' �'' <br /> �Ptt�F Grout Inspection <br /> by Date Dat <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 1123-7104 0 Tiacy <br /> d <br /> Applicant-Return all copies to:Environmental Health Permit Services'J6p1 E-.-Hazoltort Ave.,P O -box 2M6, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEE? CASH <br /> RECEIVED BY DATE P RMIT'NO. <br /> INFO a <br /> +.EH 13-24(REV.i H 5) <br /> EH 14-26 GD 1 SQ <br />