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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 andlor 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 Sart Joaquin <br /> Local Health District. <br /> Job Address �� S GT City Lot Size PM <br /> I <br /> Owner's Name Go, Address Z�SZ4� S ' Phone <br /> Contractor + �"� �� Address S L&3Q)tkk� License No, /_ '7>=3'� Phone �a6Z 6179 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCT <br /> PUMP INSTALLATION SYSTEM REPAIR © THER <br /> DISTANCE TO NEAREST: SEPTIC TANK bQW SEWER LINES Obi DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL UL OTHER WELL �� r PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LD Industrial ❑ Open Bottom 1-1MantecaDia. of Well Excavation Dia. of WL-11 Casing <br /> ^ o9fyd�4CJ�[+ditlSj lKGravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public F Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation t�-j�'?Approx. Depth I 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 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'; REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other tA <br /> Number of living units: 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. L1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS Ll Distance to nearest: 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 /> 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> II Signed X L~"i ' Title: QJC- T �—S� Date: g- <br /> li FOR DEPARTMENT USE ONLY � -20 <br /> 1950 k� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by ` Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑'Lodi 369-3621 El Manteca 623-7104 ❑ 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 MOUNT DUE AM UNT REMITTED K H RECEIVED BY DATE PERMIT`NO. <br /> INFO I <br /> + EH 1324 MEV.1/H 51 � / <br /> EH 14-2e L (;7---- <br />