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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1�2_4 1 <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.. 11hh �7+ <br /> Job Address V City Lot Size "'f PM <br /> Owner's Name Address 7sgm -IPhone <br /> Contractor's Name License No. ` ► Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT/❑}/�i .DESTRUCTION ❑ <br /> ' 'PUMP-INSTACG4TION"❑ SYSTEM-RE AIR IIj­ -- —OT HER-❑- -- --- <br /> DISTANCE TO NEAREST: SEPTIC TANK , . -. . SEWER LINES <br /> ZL,11,- SE _ R DISPdSAL FL6:- _ PROP. LINE <br /> i-,.J-FOUNDATION - -- A�R16ULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bott6m-11'-` -'❑-Manteca;r te Dia. of Well Excavation' Dia. of Well Casing <br /> ❑ Domestic/Private,.-.` t❑ Gravel Pack Q Trac Type of Casing <br /> - ry f YP 9 Specifications <br /> f Public ' � ❑ Other C] Delta Depth of Grout Seal f Type of Grout <br /> frngationL, �4pp x. Depth ❑ Eastern Surface Seal Installed by r <br /> Repair,Work Done ❑ Type of Pump H.P. <br /> 1 r —,State Work Done 1 <br /> Welf' estruction ❑ Well Diameter Sealing Material (top 50') } <br /> Depth �' Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (N6 septic system permitted if public sewer is r)✓ <br /> available within 200 feet.) y' <br /> Installation will serve: Re dance� Commercial Other M' 1 t7 <br /> Number of living units: Number of bedrooms F' LA,0-10��VV0 <br /> Character of soil to a depth of 3 fest: j �-, "! LP <br /> p U�' `� Watertable depth '� <br /> SEPTIC TANK S. Type/Mfg Ca ac y <br /> P tY'* -- No. Compartments <br /> PKG. TREATMENT PLT. ❑ A Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE $ No. & Length of lines `` Total length <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS A Depth 2s, Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ Y a <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 Wcal:Health,`District. 1,` .yam J. <br /> Home owner or licensed agent's signature certifies the following: "I certify that iii 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 lao liforni " <br /> The ap licant st II or all requ' spections. Complete drawing on reverse side. p p <br /> Signed Title:C Q&sw L&:r 1r Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> I or Grout inspection by Date.1 Final Inspection by ���-� Date <br /> �J 1 <br /> Additional Comments: <br /> Cl 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIY'NO. <br /> INFO CASH <br /> +EH13-24(REV.10/831 <br /> EH 1426 <br />