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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 Ryles and Regulations of the San Joaquin <br /> Local Health District../g / ) <br /> Job Address�7—/I�� <br /> Ci Lot SizeCAtiLQ,A_7 PM <br /> Owner's Name Address_Aa3 Phone <br /> Contr.. t t 1 �C� Address 'Li / <br /> cense No.s O (" Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL--REPLACEMENT ❑ DESTRUCTION ❑ " <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> 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, <br /> i, of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing '1 <br /> Specifications � <br /> ❑ Public ❑ Other ❑ Delta Depth of-Grout Seal - rType of Grout ' <br /> Cl Irrigationqpprox. Depth ❑ Eastern -_ q <br /> _Surface Seal Installed by <br /> I <br /> Repair _me <br /> -Work Done ❑ Type of Pump - +I.P: �\ ` $tate Work Done <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _�+� <br /> TYPE OF SEPTIC WORK: NEW INSTALS 4TION REPAIR/ADDITION 17 DESTRUCTION El (No' system permitted if public sewer is <br /> f// available within 200 feet.) ; <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms t� <br /> Character of soil to a depth of 3 feet: Water tablasdepth 7 <br /> SEPTIC TANK (� Type/Mfg I f —Water <br /> No, Compartments A <br /> PKG. TREATMENT PLT. ❑ i r Method of Doposal <br /> Distance to nearest: Well Q + Foundation �d Property Line <br /> LEACHING LINE IK No. & Length of lines O Total length Isize—ZR6 X <br /> FILTER BED ❑ Distance to nearest: Well Foundation i0 _ Property Line <br /> SEEPAGE PITS ❑ Depth Size < <br /> Number '�' <br /> SUMPS 11 Distance to Clearest: Well Foundation Property Line4 <br /> DISPOSAL PONDS CIt` <br /> 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ti <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. <br /> certifies the following:"I certify that in the performance of theContractors hiring or sub-contracting re <br /> b contracting signatuwork for which this permit is issued, I shall employ persons subject u workman's compensre <br /> tion laws of California." <br /> The applicant must call for II required inspections. Complete drawing on reverse snide. <br /> Signed X Title: y Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by "gate ) V a Area <br /> d <br /> Pit or Grout Inspection by Date Final'Prispectidn by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 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 /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY ;DATE�t� PERMIT"NO. <br /> EH 13-24(REV.i/a5)EH 1428 / <br /> i <br />