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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. q { g <br /> Job Address city Lot Size �' `-3 PM <br /> Owner's Name Addressdgd Phone tl <br /> , <br /> Contracts Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELT 6 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> _ PUMP INSTALLATION-!t .,_..SYSTEM REPAIR 0 OTHER❑�,,.�. <br /> DISTANCE TO NEAREST: SEPTIC TANK 4 SEWER LINJ-S DISPOSAL FLD. PROP. LINE <br /> 1, 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 /> ..%— <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth 1 ❑ Eastern Surface Seal Installed by *'%L l <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter .-VI Sealing Material Itop 50') � ` � <br /> . - 4' 'l <br /> Depth ,...Filler.Material (Below50'),- ---,..,-.,,,r.4-. _0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> -- ^-- —��available'withjn 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of"bedrooms <br /> Character of soil to a depth of 3 feet: AV--'2 Water table depth <br /> SEPTIC TANK Type/Mfg --�Capacity� d tNo. Compartments <br />�~ PKG. TREATMENT PLT. ❑ k �� . + r e <br /> %Method offDDispopal <br /> D Lance to nearest: Well 0 Foundation f '15roperty Lines Lam' <br /> LEACHING LINE No. & Length of lines Total length/size 25 ©© <br /> FILTER BED C Distance to nearest: Well D Foundation---5 0 Property Line <br /> SEEPAGE PITS Depth Size Number f <br /> SUMPS ❑ Distance to nearest: WeilXO�5 Foundationt7 04­ <br /> DISPOSAL <br /> Lina 2-1 <br /> DISPOSAL PONDS ❑ A <br /> I hereby certify that I have prepared this application and that Ithe wo?k will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. It *. 1 # <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 cumpensati(ii 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." X �q 1 V The applicant must call II requ' inspe ions. Complete drawing on reverse <br /> side.Signed Title: �---'� Date: <br /> ... -- <br /> EPARTMENT U_SE ONLY <br /> Application Accepted by 4 Date r g Area03 <br /> Pit r Grout Inspection.by Date( U`S� Final Inspection h C) to -7 <br /> Additional Comments: / <br /> ❑ Stk 466-6781 El Lodi 3W3821 © Manteca 823-7104 Tracya <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 35201FEE `� f <br /> INFO AMOUNT DUE AMOUNT REMITTED C RrECEIVED BY DATE PERMIT NO. <br /> z EH13241REV.I/as) c211 <br /> EH 14-28 5-S (��1�� <br />