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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 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. A <br /> Job Address ;RA-36,? S 0J t!!4/V4& , ,4ve City_`%141 AeCA Lot Size -7- -4C'*'rf PM <br /> Owner's Name �"�a0 011'-7e Z Address all 36B s" p4E'�Ilezr Phone <br /> Contractor's Name A!5/¢H' -:57, <br /> License No. y� � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 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 /> ❑ Public ❑ Other 0 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done p <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONJ$ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence X Commercial_ Other l n <br /> Number of living units: Number of bedrooms Jr <br /> Character of soil to a depth of 3 feet: s/iA'W Water table depth !d. <br /> SEPTIC TANK In Type/Mfg Casey ire Cys-7 Capacity Z-q_' 0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 8•s" Foundation !o Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1.5— - 4 Total length/size L5~5 F <br /> FILTER BED X Distance to nearest: Well 64 Foundation �o` Property Line <br /> SEEPAGE PITS _- ❑ Depth Size Number <br /> SUMPS ❑ 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 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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must 11 for all required inspections. Complete drawing on reverse side. <br /> Signed X ,Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byp Date ' `'7— 9- — Area' .F 13 <br /> N <br /> Pit or Grout Inspection by Date Final Inspection by Date 12 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 0 Tracy 835-63B5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2003, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMlfNO. <br /> + EH 13.24 IREV.10/831 .5 O p <br /> EH 14-28 <br />