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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address — /. GSD A9_/745 <br /> City Lot Size PM <br /> c <br /> Owner's Name 14&rAi&F Address E4—iT $ <br /> Phone <br /> Contractor r L�iC: Address 7� License No. <br /> CA, Phone <br /> TYPE OF WELL"/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES __ DISPOSAL FL_D. PROP. LINE _ <br /> -FOUIVDATION7--- "—"AGRICULTURE WELL OTHER WELL PETS/SUMPS + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation _.,__Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50'I <br /> Depth Filler Material (Belo 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (Noaye septic system permitted if public sewer is available within 200 feet.) <br /> Installation will serve: Residence Commercial then <br /> Number of living units: <br /> —I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: 3 ti t <br /> r r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. El _ Capacity 170fi1,J� No. Compartments : <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line `ice <br /> YLEACHING LINE No. & Length of lines r'7r Total length/size <br /> f=1L+TER, E ! ' �r7 : T l <br /> �.� ❑ Distance to nearest;' Wgfl��� Foundation Property dine_.1211_—�_ <br /> SEEPAGE PITS { { <br /> ❑ Depth - -�' � Size' Number <br /> SUMPS ❑ Distance Ro to Well Foundation Property Line <br /> DISPOSAL PONDS Cl � r <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San J6aquin county ordinances tate laws, and <br /> Q <br /> rules and regulations of the San Joaquin Local Health District { <br /> Home aw'ner or lit ensed agent's signature certifid'the following: "I certifif that in the performance of tie work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to:workMgt's compensation laws of California."'Contractor's hiring-or sub-contracting signature rt ' <br /> certifies the following: "I cern that in the rformance of the work1or which this errhiit is issued;I-shall em to <br /> f1r Pe <br /> tion laws of California."�t �A'_ a p P Y Person'supjec�t o workman's compensa- <br /> The applicant must call for re inspections. Complete drawing on reverse side. r� r <br /> Signed X <br /> i Title: Date: SIV p <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate <br /> Area - <br /> Pit or Grout Inspection by Date Final Inspectionby ' t <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi $69.3621anteca 623-7104 E] Tracy 835-6385 ` <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1607 E. Hazelton Ave., P.O. Box 2009;Stk., CA 95201R , <br /> FEE. l7UE` '— '"AHfOUNT REMIFTED" <br /> INFO CASHT RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-A ipEV.i/ <br /> EH 1428 / ' <br />