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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f— <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. <br /> Job Address �+�(E21(L /V, //�TJ� �/ / City Lot Size PM <br /> Owner's Name T LES Address /��� ,��� � hone <br /> y 4 7r w � / <br /> Contractor d1 121 /tl S �Tr�] Address jq J I7 License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW•WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.Id7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 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 /> l_I Public n Other Fl Delta Depth of Grout Seal .. Type of Grout _ <br /> I 1 Irrigation Approx. Depth I I astern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. . r�lS _. State Work Done <br /> Well Destruction J& Well Diameter - �- Sealing Material Itop� v C"'fl1���LF <br /> Depth Filler Material {gelow✓/fit' JUl� __ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATfON I I REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 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: Water table depth [� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <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, 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-contractin 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 ompensa- <br /> tion laws of California." <br /> The applicant t for 11 requtr n pections..Com�pl�te-drawing on reverse de. <br /> Signed X-_�/� :s%/�f�Title: Date: <br /> �O EPMMW� T USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by (� Date Final Inspection by Date f <br /> Additional Comments: t ex, r`--�� �-\ - S C� 1 U-16�� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635- b 1"N <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE <br /> AMOUNT REMITTED CK GASH RECEIVED BY DATE (� PERMITi NO. <br /> +.EH 14-24[pt:V.t i H 57 35 LJ u <br /> EH 14-28 L�f 1 U U00 <br /> U <br />