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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 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 /> i. �.���� r►� <br /> Job Address City Lot Size M <br /> �.rP+�j <br /> Owner's Name Address Z� Y �n�� lapPhone 44 , 1$ <br /> -Contractor4a:PA ?J rip Address'[ License No. Phone70~'2i:74' <br /> tP <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 COP;S-TliUCTIOW SPECIFICATIONS �! 46M <br /> ❑ Industrial Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing CC Specifications <br /> (`l Public n Other ❑ Delta Depth of Grout Seal Type of Grout <br /> re <br /> I I Irrigation _Approx. Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> s <br />„ Well Destruction � Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 (Nn septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence__Commercial Other <br /> �hNumber of living units: Number of bedrooms i � `;A <br /> Character L4 soil to a depth of 3 Meer. t Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity S', No. Compartments <br /> PKG. TREATMENT PLT. ❑ v _z _ �>wMethod of Disposal. <br /> Distance to nearest: Well Foundationv.. property Line = ! <br /> LEACHING LINE ❑ No. & Length of lines ' `� Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I 1 Depth Size i Number <br /> r"'g'SUMPSj, r. Cl -Distance to nearest •Well Foundation` '°'^` '�"`"Property Line+ - <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accor"dance with San Joaquin county ordinances, state laws, and <br /> ­r@1es and fegulations-of the San Joaquin-Locat Health Di?;trict. -- <br /> Home owner or licensed agent's signature certifies the following: "I certify-that in-the performance of 1he-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 certif at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion , <br /> tion laws of California." <br /> The applicant must equired inspections. Complete drawing on reverse side. ` r� <br /> Signed X 2 A — Date: 10 4V <br /> =.FOR DEPARTMENT USE ONLY r <br /> Application Accepted b Date1 Area <br /> Pit or Grout Inspection(, ) Date 1 Final Inspection by r Date/ <br /> Additional Comments: . •`,..,- <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Mente 623-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BYT <br /> INFO DA E PERMIT NO. <br /> +.EH13-24 IREV.i i n sl ] y (2 \L{ Gt <br />