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_ y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> qoil <br /> 1601 E: HAZE;_TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I` PERMIT EXPIRES 1 YEAR FROM BATE 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 /> Applica <br /> j for sewage or No. 1662 for weli/pump and the Rules and Regulations of the San Joaquin <br /> made compliance with San Joaquin County Ordinance No.549 <br />. Local Health District. <br /> (12 City C Lot Size PM <br /> I Job Address <br /> �'y3 _ Phone <br /> 9675?-3 <br />} Owner's Name <br /> Address __'' <br /> of License No..? S 7.Z/ Phone 3 3133 <br /> Contractor PJ Address <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: . NEW WELL O SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> ( SEWER LINES DISPOSAL FLD. PROP. LINE i�'•U, <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL j <br /> Ij <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ElOpen Bottom L1Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> I <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grog Seal Type of Grout <br /> I i`l Public F Other C-1 Delta <br /> ` I I Irrigation —.-Approx. Depth 4 I Eastern Surface Seal Installed by <br /> IH P State Work Done _ <br /> I Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION-6'I.- REPAIR/ADDITION I+I�DE ST-RUCTION 1 I available rwi hin 200 fesystem retued if public sewer is <br /> Installation will serve: Residence_L <br /> — Other <br /> Number of living units-,__L_ Number–of bedrooms--2-- Water table depth o <br /> l ( <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> + SEPTIC TANK F1Type/Mfg Capacity <br /> Method of Disposal <br /> I PKG. TREATMENT PL-T. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE 'L'1�No; & Length of lines <br /> [ Total length/size 10 <br /> f <br /> Property Line /01 <br /> FILTER BED Ll Distance to nearest: Well Foundations , - <br /> y Number <br /> SEEPAGE PITS 1411�Depth ipt ' Size r l <br /> SUMPS <br /> ❑ Distance to nearest: Well Q,�— Foundation 1 ; Property Line�_— <br /> r DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordant. 1 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 followir g: 'I certify that in the performance of the work forewhich this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workrfian'.s compensatiori laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work far which this.permit is i`ss�d,i shall employ persons subject to workman's oompensa <br /> tion laws of California." <br /> . � <br /> The applicant must c I for all required inspactionsComplete drawing on reverse side. 2a <br /> ,, L J <br /> r Title: Date: �7 <br /> Signed X } I <br /> x1 FOR DEPARTMENT USE ONLY <br /> Date <br /> J� Area <br /> k Application Accepted by <br /> ii or Grout Inspection by Date€-/ Fine) Inspection by <br /> } <br /> Additional Comments: El Tracy 835 6385 <br /> ❑ Stk 466-6781 El Lodi 369-3621 11 Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/ServiceS 1601:E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> T REMITTED GASH <br /> EArHs <br /> a EH 13-241KV.1/nsl <br /> EH 14-2e <br />