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C <br /> APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> .I <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,fiegulations of the San Joaquin <br /> Local Health District. <br /> Job Address r, ~� �;,�/ 2;1W Citv,40. Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor's Name- .J% t-i��1 i _License No:�c? fi -!Q;­ <br /> —TYPE <br /> Q;TYPE OF WELL/PUMP:. -:`T -„.NEW WELL ❑-_ WELL,REPLACEMENT 0 1�:.-E DESTRUCTION ❑ <br /> E - CTO 0 <br /> --. PUMP-INSTALLATION,-LJ.,..,.:.�,.,.- .SYSTEM REPAIR_❑_..,—f .� OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES "`'” DISPOSAL FLD. PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL.-_PF�SUIVIPS <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA' -CONSTRUCTION SPECIFICATIONS-- �t' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by l <br /> Repair Work Done , CJ Type'of Pump H.P. State Work Done <br />} Well Destruction ❑ Well.Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system public sewer is 1},q <br /> avrgilable.within 200 feet.► <br /> Installation will serve: Residence.-` Commercial_ Other M <br /> -Number of living units: Number of bedrooms y. <br /> Character of soil to a depth of 3 feet: 5&1iDu 1 ezM Water table depth ' <br /> SEPTIC TANK XL.T'ype/Mfg --f Capacity / res No. Compartments <br /> PKG. TREATMENT PLT. ❑ .} �'`� Method-modfDisposal <br /> Distance to nearest: Well ' ' Foundation Propertyxirie <br /> LEACHING LINE ❑ N J <br /> a. & Length of lines � �X �/? �-`"'� ' ^ 1`otal-lengtFi%size <br /> FILTER BED 1 Distance to nearest: Well Foundation sz Pro/p�erty Ly, <br /> ine <br /> '" <br /> SEEPAGE PITS ❑ Depth -S ize Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line tf " <br /> i DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared-this-application-and-that-the,work-wilI-be-done-in-accordance w4(-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 must call for a req 'ped inspections. Complete drawing ort reverse side. r <br /> Signed X Title: Date: <br /> ^-^-�- - -FOR-DEPARTMENT-USE'-ONLY -41 G; j <br /> Application Accepted by Date =�-a_ Area r �j <br /> Pit or Grout Inspection by } Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 1 369-3621 ❑ Manteca 823-7104 ❑ 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 /> IFEE NFO AMOUNT OUE y F AMOUNT REMITTED % CASH' RECEIVED BY ,DATE PERMlff`NO. <br /> + (REV.101831 <br /> EH 14-26 s- 3 �3-5-�►(� ' <br />