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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> �i Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 __ r�'J -�.,- City <—V Lot Size� PM <br /> Owner's Name ��, �,�1j + ti Address Phone 4 <br /> rte" R- --- <br /> Contractor Address License fVoo��s;Si�� Phone Aft <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL -Pi1OBlLEM`A'REA CONSTRUCTION SPECIFICATIONS <br /> } ❑ Industrial ❑ Open Bottom El Mariteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing ' <br /> Tracy Yp 9 Specifications <br /> 1 I`1 Public D Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I ] Irrigation <br /> --.Approx. Depth l I Eastern Surface Seal Installed by <br /> _ fRepair Work Done C7; ti Typetiof_Pump H.p,w State Work Done <br /> Well Destruction J Q. , Well Diameter I Sealing Material (top 50.1 <br /> a <br /> Depth Filler Material lBelow 501 <br /> TYPE"pF.-SI PT.fG.WDRKc!-`NIIN,INSTALLATION REPAIR/ADDITION l i DESTRUCTION I I INo septic system permitted if public sewer is I <br /> - <br /> " available within 200 feet.) <br /> .. - ds - --. .1 .�-- •. �... <br /> a <br /> Installation will serve: Residence Commerdlal .�_Other <br /> P 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 1 �-�- Capacity -_ , No. Compartments <br /> 1 PKG. TREATMENT PLT. Cl,•, _ 1 "'• . f <br /> Method of Disposal r <br /> a n t r <br /> Distanc —�r o�a{ Property e to nearest: <br /> ;1iVell Foundation �"Pro ert Line <br /> 1 LEACHING LINE :;No. & Length of lines.._41 <br /> Total length/size 7` <br /> FILTER BED D Distance to nearest: IWell"r undationr <br /> f s�Gam=? Property Line <br /> 'q s <br /> SEEPAGE PITS I I Depth �7~ _Size—_.:l �_ Number - <br /> i <br /> SUMPS /ice Distance to nearest Well `d Foundation " Property Line' <br /> DISPOSAL PONDS /❑ 1 <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 Diltrict. <br /> Mame owner or licensed agent's signature certifies the following: "I•certify thaOrr 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 Iaws,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 peisons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call fo all re ired inspections. Complete drawing on reverse side. <br /> 1 <br /> Signed X Title: Date: f�� / T <br /> - y EPARTMENT USE ONLY <br /> {I{ <br /> Application Accepted by Date rea r <br /> jPit,or Grout Inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> D Stk,. ,466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 }' <br /> l Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P,O. Box 2009, Stk., CA 95201 <br /> 'FEE- """"AMOUN7DUE Afv1QlJNTftEMITTEDK.. f <br /> INFO CASH RECEIVED BY ­ pATE" '�PERMrT'NO- " <br /> I <br /> a.EH 13-24(RFV,1/n 51 1 <br /> FH 14-20 Q I+ I O 9 O--7c:) <br /> . - <br />