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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA , <br /> Telephone (209) 466-6787 , .'�",' <br /> �` a if �n PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to theSan<<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 Joao n bounty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. fr <br /> f <br /> Job Address City Lot Size f 330 PM <br /> Owner's Name Q `` w Address -Z' Lin- Z Phone72- S <br /> 1,,Contractors Name License No:- Phone—337 _ <br /> TYPE OF',WEL-L/PUMP: NEW WELL` �4 ' WELL R'EPEACEMENT,❑ `::DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM,REPAIR ❑ OTHER ❑ ; <br /> " DISTANCE TO NEAREST:'.SEPTIC TANK SEWER-LINES ! DISPOSAL FL-D: PROP. LINE- `+ <br /> FOUNDATION AGRICULTURE WELL r OTHER WELL PITS/SUMPS%D5' <br /> INTENDED USE TYPE OF WELL \PROBLEM AREA CONSTRUCTION SPECIFICATIONS ►� <br /> EI Industrial KOpein Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> j�`Domestic/Private El Gravel Pack nracy Type of Casing � e-- Specifications . 156 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation r---Approx. Depth ❑ Eastern`., Surface Seal Installed by <br /> Repair Work..Done "❑ Type of Pump iH.P'- 1 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> Depth Filler Material (8elow.5d'). E - 0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-D'-DESTRUC710N ❑ (No septic system permitted if public sewer iso <br /> / ­1 available within 200 feet.I <br /> Installation will serve: Residence_ .Commercial Other f <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}�'�- `.r f Capacity —.No' Compartments <br /> PKG. TREATMENT PLT. ❑ f ,# o Method of biaposal <br /> Distance"to.nearee,ts• •,Well Fouridation Property Line" � <br /> i I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE-PITS- _ — —E]"-Depth - -Size- <br /> SUMPS <br /> SizeSUMPS ❑ Distance to nearest: I Foundation Property tine <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 df-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."Contractors fining'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." F . <br /> The applicant st II for all requir " inspec' Complete drawing on reverse s��ide..""�� <br /> Signed l Title: L� Date: 30 �. <br /> F R DEPARTMENT USE ONLY <br /> IJA <br /> Application Accepted Date Areaol <br /> �� Final Inspection b pate i <br /> Pit or Grout fnspectio Date pe y <br /> Additional Comments: `. I <br /> ❑ Stk 466-6781 ❑ Lodi{359-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies toi Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED✓. CASH RECEIVED BY DATE PERMIT NO.' <br /> CK 4+ Eli 13-24(REV 101631 � � � 196-`��3 <br /> EH 14-26 1 d S.- c7� <br />