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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Teleph he 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> A <br /> Application is hereby made•to the San Joaquin Local Healfh 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,649 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> * Local Health District. <br /> + ! 1t <br /> E 7 i <br /> Job Address ! f City G7Z of Size PM <br /> Owner's Name, (/1 A '/! 1 Address 271 1 �a �rs bt Z Phone <br /> i / r <br /> Contractor <_Address �� o License No. Phone <br /> TYPE OF WELL/PUMP:1—°2`_`" NEW WELL )1ZWELL REPLACEMENT [IDESTRUCTION El PUMP.INSTf1tb4l0N S'FS-T-EM-REPAIR--R-- <br /> DISTANCE <br /> EIti/l-REPAfR C7 ---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 910pen Bottom ❑ Manteca Dia. of Well Excavatio Z Dia. of Well Casing <br /> i F-Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S Specifications <br /> r ❑ Public ❑ Other ❑ Delta Depth of Grout Seal /�� �� Type of Grout <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by cY Su <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done , <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth A f7, ; _ Filler Material (Below 50'1 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REP R/ADDITION f I DEST UCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> -2-Installation will serve: Residence— Commercial Ot er <br /> may_ Number ofiivi-ngYunits,= Number.of,bedrooms <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- © • <br /> ¢ y Method of,'Disposal <br /> Q. Distance to nearest'.�Well. F ndation"- Property Line— <br /> A -- . <br /> LEACHING LINE a ❑ r No. & Length of lines Total length/size <br /> FILTER BED r t I❑ Distance to nearest: ell Founda"on Property_Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to near st: Well Foundation 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 /> f employ any person in such manner as to becomeb <br /> subject to workman's compensation laws of California." Contractor's hiring or su -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 fo workman's compensa= -,, <br /> tion laws of California,-_ . „_� <br /> The applica t call r all re ired i coons. Complete drawing on reverse side, <br /> Signed X Title: k E-A - Date: Kv <br /> FSEJONLY �- <br /> Application Accepted by Date `�r r�C> Area <br /> Picu by Date Final Inspection by Date <br /> Additional Comments: <br /> ElStk 466-6781 ❑ Lodi 369-3621 ElManteca 823-7104 Cl Tracy 835-6385 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 55201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 13-24(REV.tia sl O KIy <br /> EH 14-26 �C�`� ��L/if <br />