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r - <br /> APPLICATIO_N FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED"` <br /> (Complete in Triplicate) <br /> - , <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 Ryles and Regulation of t�h»e Soman Joaquin <br /> Local Health District. <br /> Job Address '2I / <br /> �� GL��/"' •e city t Size ..',. ' PM d <br /> Owner's Name �n1ti1 6, r i le 191t Address Phone cef <br /> Contractor Address License No. - Phone <br /> TYPE OF WELf�IPUMP: NEW-WELL-ED ,,�WEL"L-REPLACEMENT C: , DESTRUCTION ❑ *- <br /> PUMP INSTALLATION ❑ SYSTEM .REPAIR ❑ OTHER ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL. : OTHEFNVELL `y'`4 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;gib <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of`Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing.L Specifications <br /> ❑ Public El Other ❑ Delta Depth of Grout Seal Type of Grout <br /> a ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by �� 1 <br /> Repair Work Donee Q' Type of Pump H.P. I State Work Done M. , <br /> Well Destruction ❑ `I Vell`-Diameter fes ` T <br /> Sealing Material Itop 50') >.f - <br /> f ± Depth; "-f f Filler Material (Below 507-_' ' S <br /> TYPE OF SEPTIC WORK: .,NEW INSTALLATION_"$k. REPAIR/ADDITION ❑ DESTRUCTION ❑-(No septic system permitted if public sewer is <br /> Y t available within 200 feet.) # 9 <br /> Installation will serve:' Residence Commercial= Other c: ; �/ _ 0 <br /> Number'of living units: Number of bedroomsy <br /> Character of soil to a depth of 3 feet: _ I Water table depth al <br /> SEPTIC TANK �� Type/Mf'g O •r Capaci {L <br /> -QIP° - - tY Compartments <br /> PKG. TREATi1AE T PLT. Q *7 .L� --- _. r Method of Dispa <br /> pl <br /> d � .s f .Distance'to nearest: - (Nell� Foundations Property Line� <br /> LEACHIN0 LINE V� No &..Length of-lines t f- �otal lerlgth/ Z size U , <br /> - FILTER BED" ­Distance to nearest: Well.�-U ' ,L Foundation-A? Property Line <br /> SEEPAGEPITS ❑`"Depth- = f Size # Number <br /> SUMPS t �- -❑ .Distance tc nearest:l .Well- - - s .Foundation 4 Property Line <br /> DISPOSAL PONDS ❑ _ o- <br /> I hereby certify that I-have prepared this-application and that,. e_.oik will be daKe in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. i <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 must call for all required'i spections.'Complee drawing on reverse side. �- <br /> Signed _ e Title: Date: <br />€ FOR DEP ARTM T USE ONLY <br /> Application Accepted by Date ���Area <br /> s <br /> Pit or Grout Inspection by � � Date - Final Inspection by ' Data <br /> Additional Comments: <br /> s ❑ Stk 466-6781 L7 Lodi 369-3621 XqAanteca 823-7104 ❑ Tracy 835-6385 1 <br /> 'Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT;DVE AMOUNT REMITTED IL <br /> RECEIVED BY DATE PERMIT"NO. <br /> +EH13-24(REV.1/a a1 � ,Ly <br /> EH 1426 1 <br /> e � 4 <br />