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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 TYEAR FROM DATE ISSU D <br /> (Complete in Triplicate) SEP 2 1 19PO <br /> Application is hereby made to the San Joaquin Local Health District fora Permit to construct and/or int ! 9"s ri 1s lication is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and t � TA �i �i .T4 <br /> Local Health District. � ���� p5othe San Joaquin <br /> Job Address W w City L0,4 J Lot Size Ply ' <br /> Owner's Name Tt kc Address / / 4 /2- _ Phone-d--) <br /> Contractor Address10,*,At G 7 LiceNo. ��+�-.J Phone 7/ D <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ l® r; SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE;WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation l Dia. of Well Casing <br /> omestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other t i Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I 1 Easte n Surface Seal Installed by � I <br /> Repair Work Done ❑ Type of Pump SI✓� 'H.P, _ State Work Done f 4C7-P <br /> Well Destruction ❑ Well Diameter Sealing Matepiial Itop 50'1 <br /> Depth :Filler Material(Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') RE AIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) _ <br /> 'Installation will serve: Residence Commercial f�Other i <br /> Number of living units: Number of bedrooms r j <br /> Character of soil Wa�depth of 3 feet: 1 Qu <br /> �, i ; r Water table depth <br /> SEPTIC TANK.,;,,.,,,,—, —jO :Type/Wg _Capacity �No Campartmenis, <br /> PKG, TREATMENT PLT. ❑ ' w� Method of Disposal <br /> Distance to nearest: Well oundation i �. Property Line I <br /> v l <br /> LEACHING LINE ❑ No. 8, Length of lines 9 Total�length/size i <br /> FILTER EKED ❑ Distance to nearest: Well " n ­tI I Property Line <br /> SEEPAGE PITS 11 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 wi IL,be done in accordance with San Joaqun'counly ordinances, state laws, and 1 <br /> rules and regulations of the San Joaquin Local Health Diktrict. <br /> Home owner or licensed agent's signature certifies the following: "I certif..,that in the performance of the work forhich this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's.tolnpensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: '9 certify that in the performance of the work for whlch this permit is issued, i shall employ per=sons subject to workman's compensa- <br /> tion laws of California." <br /> The applican st tali for all re wired inspections. Complete drawing on reverse side. I <br /> ISigned X tie: i <br /> Date: � <br /> FOR DEPARTMENT USE ONLY ��// t <br /> Application Accepted.by Date_(' Area <br /> Pit or Grout Inspection by Date Final Inspection b Date V—t [) <br /> Additional Comments: " <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +_EH 13-24(REV. <br /> EH 14-26 <br />