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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 361, G <br /> 1601 E. HAZEL T ON 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address '�� City Lot Size tyYF-S PM I <br /> Owner's Name `>�V.7 t,36 S Address Phone sa ` <br /> bN, cCG32 �2r3— ct Il <br /> Contractor ke Address 10 License No. "fdELI Phone <br /> TYPE OF WELL/ MP: NEW WELL ❑ WELL REPLACEM NT ❑ 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 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 /> f'] Public Ll Other F] Delta Depth of Grout Seal Type of Grout--­ <br /> I <br /> rout _-.I I Irrigation —Approx. Depth l I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION K DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____ Commercial— Other <br /> Number of living units: _j— Number of bedrooms Z-- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 50 Foundation 6w-Property Line IDOL <br /> SEEPAGE PITS I I epth Size Zlk r�_ Number �,, <br /> SUMPS L`i Distance to nearest: Well�Q_I2 foundation 60 0 Property Line�� <br /> DISPOSAL PONDS ❑ <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 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican t c I for all re uired inspect n . Complete drawing on reverse side. <br /> Signed Title: Date: [ [ <br /> DT NT USE ONLY 7 <br /> Application Accepted by I. A Date + Area :3 ®Q <br /> Pit o�rr`a�t Irispection by ate 9--j-5:u Final Inspection by Date 9-4<o f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 ❑ 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 INFO MOUNT DUE AMOUNT REMITTED JV 2 CASH RECEIVED BY_ DATE PERMIT NO. <br /> +. <br /> EH 13-M TREY.t/H s7 [V� 2i[.J r �U 1,2 7 Z-'_✓ <br /> EH 1A-2tt <br />