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s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �. ! 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> �1 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 /> j14Q�1 �Q J City 4z4 Lot Size ''S Ac.-te, PM <br /> Job Address ' / � <br /> Owner's Name/%�a%��""�� ��/ �/ ss���� ° //t�u"rAe C�fi/I�Gz'" Q�3�Phone®.2G —;?'Z <br /> Contractor f Address gq� License No. Phone <br /> TYPE OF WALQPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ''. TVft bF WELL ' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial' El Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/.Priv .� •❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout--­ <br /> I <br /> ut __I I Irrigation , —..Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done `❑ •type of Pump '" H.P. State Work Done_ <br /> Well Destruction ❑4 Well Qielneter Sealing Material (top 50') <br /> Dept- ,* � _ Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEk#INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> '9.4 available within 200 feet.) Q <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <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 L Foundation �S z Property Line / r <br /> SEEPAGE PITS 0 ' Depth Size _ Number <br /> SUMPS LljDistance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <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 applicanLjw4st call for al required inspections. Complete drawing on reverse side. <br /> Signed X T Title: Q�Z� Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by ^. Date —' —00Area 13 <br /> 11 <br /> Pit or Grout Inspection by Date Final Inspection by Datez4e�?v <br /> lee <br /> Additional Comments: <br /> ❑ Stk 466-6781 O 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 DATE PERMIT NO. <br /> INFO CASH <br /> a,EH 13-24(REV.1/x 5) -711'Z L <br /> EH 14-28 0 T <br />