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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT toiE <br /> 1601 E. HAZELTON 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 2 5—-2 City 122< Lot Size,/S 25 X '6W - PM <br /> Owner's Name eF' `�"LS'!- C71_aAL'4' Address Phone <br /> Contractor's Name /JQfiR�, /f/� 9rS dam' License No.' Z42 _ -- - Phone dz�, ­96 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ (� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ y 1 <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 /> ElPublic C1Other ❑ Delta Depth of Grout Seal Type of Grout r <br /> ❑ Irrigation ---Approx. Depth 171-Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. _ State Work Done a� <br /> Well Destruction ❑ Well Diameter Sealing Material {top 541 \ <br /> Depth' _F_il"atedaLlBelow 501 <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence� Commercial— Other <br /> Number of living units:--/— Number of bedrooms _2— <br /> Character of soil to a depth 9f 3 feet: �/iF�� Water table depth <br /> SEPTIC TANK i9" Type/Mfg ,?� zlzz Capacity /zn r No. Compartments Z <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well --Foundation 1d Property Line S4 <br /> LEACHING LINE Lir/No. & Length of lines 3 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -46 Z Foundation 20 Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 applicant mustcallfor all req�uiree�d'inn"ctions. Complete drawing on revs sid <br /> Signed X Title: e Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area u // <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> >CStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95241 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERmi- NO. <br /> +EH 13.24(REV.10183) -- 15 <br /> EH 14-25 <br />