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T <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (200) 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 113 City 51X"�Vl Lot Size 7Sa 111' PM <br /> Owner's Name W 4614,6 i- 0'4 S/L L/AJ' Address S-477'@ Phone 9.3Z-9(-pe& <br /> Contractor FG P? A l re-D Address 7 A4 AW-- License No. Y-5-7e Phone 1 .3 7 7/ <br /> TYPE OF WELL/PUMP: I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR-E] OTHER 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 Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑Other ❑ Delta Depth of Grout Seal Type of Grout F _ <br /> I I Irrigation _-_Approx. Depth I I Eastern Surface Seal Installed,by ' <br /> Repair Work Done ❑ 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 Ia REPAIR/ADDITION DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other PWdZ-,Je A,,,4 72F,e <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: J-A Y Water table depth <br /> SEPTIC TANK ❑ •Type/Mfg X 15�—II 6- Capacity ;No. Compartments <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> i <br /> LEACHING LINE No. & Length of lines r Total length/size - D <br /> FILTER BED ❑ Distance to nearest: Well Foundation 2i1-/ Property Line <br /> SEEPAGE PITS C Depth Size rr _ Number <br /> SUMPS Ll 'Distance to nearest: Well_ _ Foundation'— Property Line /d <br /> DISPOSAL PONDS ❑ i <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 must call for all requireed,iinnsspectio%s. Complete drawing on reverse side. I <br /> Signed X Date: <br /> F. USE ONLY_. <br /> Application Accepted by A S&&00 is Date Area <br /> Pit or Grout Inspection by ,Date, r <r 'Final Inspection by Date <br /> Additional Comments: i <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 /> INFO UNT DUE AMOUNT REMITTED C H RECEIVED BY DATE PERMIT NO. <br /> +.EH � <br /> 13.28 24(REV. <br /> EH 14- ®� 2J 7 <br /> i <br />