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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 Ea. HAZEL 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. f p <br /> Job Address / , t City / ' Lot Size PM <br /> Owner's Name ddress <br /> vv <br /> Contractor /,Address �1 -License No. Phone � —3?1e I <br /> TYPE OF WELL/PUMP: NEW WELL JV WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION_X7 SYSTEM REPAIR ❑ OTHER ❑ ``qq <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSAL.FLD.---' PROP. LINE <br /> G —FOUNDATION � AGRICULTURE WELL OTHER WELL PITS/SUMPS ;?4&94't <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS u <br /> Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i"1 Public (7 Other n Delta Depth of Grout Seal' Type of Grout Am CAt RV 17 E <br /> I I Irrigation _Approx. Depth l I Eastern ce Seal Installed by <br /> Repair Work Done ❑ Type of Pump —:W1?1e>_ H.P. 7— State Work Done _ 5 <br /> Well Destruction 0 Well Diameter Sealing Material ftop 50') <br /> Depth Filler Material'18elow 50'I `' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I. I DESTRUCTION I f INo septic system ii&mitted.if public sewer is <br /> available within 200 feet.)."" � <br /> Installation will serve: Residence_ Commercial_ Other " 1" <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: f �x Water-table depth. + <br /> SEPTIC TANK ❑ T e/Mf <br /> Yp 9 Capacity No:Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disp so alp ► 9 /1 <br /> �• V i <br /> Distance to nearest: Well Foundatibrn "ri Property Line r 1 <br /> LEACHING LINE 0 No. R Length of lines ?' -- 'Total lengtFilsize <br /> FILTER BED 0 Distance to nearest: Well Foundation Line: r 1 <br /> SEEPAGE PITS 1 1. Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ L <br /> 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 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." ! 1 <br /> The applicant r I requi s Vis. Complete drawing on raver ide. 4 <br /> _ <br /> Signed X Title: ` �� �✓ - Date: f <br /> rD R DEPARTMENT USE ONL Application Accepted b Date Lk—4 �9AreaPit or Grout Inspection by I Final Inspection by Date g-q <br /> Additional Comments: %® <br /> .O Stk 466-6781 O Lod 369-3621 Manteca- 823-7104- ,--.- D Tracy,-835-&385 - — - -- VV --:' <br /> Applicant _Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED F CK ilt RECEIVED BY DATE <br /> INFO CASH PERMIT NO. <br /> +.EH 13-24 I HEV.I i n 51 ! � � <br /> EH.14-2e <br />