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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CA <br /> " Telephone {209) 966-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> G (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.548 for sewage or No:1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f <br /> S Job Address <br /> City L� r 1 <br /> t } � SICC DVI Lot Size U <br /> Owner's Name 1[ t Address Phone ` 4 <br /> IF <br /> Contractor AddressLicense No. <br /> yf <br /> Phone <br /> E TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <br /> i. PUMP INSTALLATION Q SYSTEM REPAIR ❑ t <br /> ALLOTHER EI_ T <br /> DISTANCE TO NEAREST: SEPTIC TANK aSEWER LINES. DISPOSAL FLD.f PROP.k6NE <br /> FOUNDATION - AGRICULTURE WELL -.0_T4R WELL i PITS/SUMPS.;-_'° <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ekca`vation Dia. of Well Casing r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑Tracy Type of of ¢ *Specifications y <br /> 1'1 Public ❑ Other P Delta depth of Grout Seal ' Type of-Grout r <br /> ! I Irrigation --Approx. Depth I ] Eastern Surface'Seal Installed by I t <br /> Repair Work Done L1 T r <br /> p hype of Pump H.P. State Work Done_ 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i <br /> Depth y. Filler Material {Below 50') <br /> r <br /> TYPE;OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I` DESTRUCTION 1-1•.(No septic-systern-perniitted'if public-sewer is v <br /> available within 200 feet./ i y <br /> Installation will serve: Residencd►% Commercial Other <br /> Number of living units: !L_� Number-of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth i r <br /> -�`�Fype/Mfg i Capacity_/_ b� No. Compartments sai <br /> PKG TREATMENT PLT. ❑ tom'" �5�•-�-ln� ' Method of Disposal t; _ <br /> Distande to nearest: Well i-t.eLL+ Foundation nd Property Line <br /> t <br /> LEACHING LINE --+"No. & Length of lines = <br /> Total length/size l <br /> FILTER BED ❑ 'Distance to nearest: Well L IM Foundation_) 0-i­� 14 Property Line_c42 r 1 <br /> '• : <br /> SEEPAGE PITS I I Depth __Size—p N'-mbar <br /> kSt1MPS J�--Distance to nearest: Well Foundation Property line <br /> DISPOSAL PONDS 0 <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, ander . <br /> rules and regulations of the San Joaquin Local Health District. �3 ! <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 i <br /> d certifies the following: "I certify that in the performance of the work for which this permit isissued,].shall employ persons'subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for all required ins tions. Complete drawing on reverse side. w <br /> r •-v_ti /• r 1 c <br /> _ Signed X7 Title: <br /> y ; <br /> FOR DEPARTMENT USE ONLY_ <br /> Application Accepted by ''fin Date �"{ ry } Area 1 { <br /> Pit or Grout Inspection by Date. Final Inspection by Date <br /> VApIi t <br /> ditianal Comments: � <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 ; <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.-Box <br /> -2009,-Stk., CA 95201 €. <br /> F <br /> ^+- FEE AMOUNT DUE AM NT REMITTED RECEIVED 8Y DATE PERMIT NO. <br /> INFO CASH 11 <br /> r• r - <br /> + EH13-24(REV.iiKs) * _,r'; <br /> EH 14-26 <br />