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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 of No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> R,9 (�"� / 9.t4i/C1 <br /> Job Address _-._ R, y V7Z' &Ae, ._ City � [� Lot Size PM <br /> Owner's Name C L . 0 I4 Address Phone Y106 <br /> Contractor Drys Address W. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM NT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAMC 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 /> F1 Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ t <br /> i I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by ✓' <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction C1 Well Diameters Sealing Material (top 501 <br /> Depth Y `' Filler Material-(Below 50.1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION X DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet. <br /> Installation will serve: Residence—Xl Commercial_ Other <br /> Number of living units: Number of bedrooms a2 9 <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. ❑ _^ j <br /> - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Na. & Lenth of lines 90 <br /> 9 Total length/size (° <br /> FILTER BED ❑ Distance to nearest:; Well Foundation Foundation �o� Property Line <br /> �V <br /> SEEPAGE PITS 1 1 Depth Size t Number <br /> SUMPS 0 Distance to nearest: Well^ FoundationProperty Line <br /> DISPOSAL PONDS 11�'" <br /> I hereby certify that 1-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 Joaquin1cical Health Do-strict. 4. <br /> ` <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'perforrnance 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 inspections. Complete drawing on reverse side. <br /> r � � <br /> Title:e: Dale: <br /> Signed , <br /> g � .. _ t_��- C•FT9 4 <br /> fI �I• EPARTMENT USE ONLY <br /> Application Accepted byf Date /2—Z r 4F <br /> rea <br /> Pit or Grout inspection by Date Final Inspection by - !J —pate <br /> Additional Comments: / <br /> ❑ Stk 466-6781 LI/Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 r'rr <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA'95201 <br /> FEE AMOUNT DUE AMOUNT REMrTTED CK RECEIVED 6Y DATE PERMIT NO. i <br /> INFO CASH <br /> �.EH 13-24'(REV. <br /> EH 14-26 �. �.- \# i .cT 4—q <br />