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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 TYEAR FROM DATE ISSUED <br /> �- (Complete in Triplicate) <br /> Application is tleieby 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. 11 <br /> ��, �C 7 <br /> I City Sem-- Lot Size PM <br /> Job Address <br /> ar1,�Pi/ N� � 9 Q� <br /> C. Addresses/tom. e�iSrw►Nei_ Phone <br /> Owner's Name _ - "� - <br /> License No r� Phone <br /> Contractor > ✓ ` Address " <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O 'OTHER ❑ k <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. r PROP. LINE <br /> FOUNDATION AGRICULTURE WELL tOTHER WELL_- PITS/7- <br /> -.,Wo <br /> tS <br /> ._„_.INTENDED-USE—.�.T-Y.PE•OF W.E'LLt "!'P -«-CONSTRUCTION SPECIFICATIONS Dia. of WellCasing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation s <br /> Type of Casing 1 Specifications <br /> 113 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Grout <br /> —-­ <br /> IPublic 11 Other Ll Delta Depth of Grout Seal <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by ti <br /> Repair Work Done LJType of Pump H.P. State Work Done <br /> 1 1 Well Destruction ❑ Well Diameter Sealing Material )top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DE=STRUCTION I I allo.,sepefwthin 200 stem permitted it public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: -L_-_ Number of bedrooms _ <br /> I � Water table depth <br /> Character of soil to a depth of 3 feet: _ r <br /> SEPTIC TANK ❑ Type/Mfg Capacity__fen g,@g— No. Compartments <br /> -' — <br /> PKG. TREATMENT PLT.0 t -d - � � Method of DispgAal - <br /> Distance to nearest: Well L'JrO— Foundation//d Property Line Ad <br /> LEACHING LINE 3§04 No..& Length of lines _ '.—�� Teal length/Size - <br /> �+ <br /> FILTER BED ❑ Distance to nearest: Well t;�O i Foundation/o �' Property tine <br /> SEEPAGE PITS Depth J ___Size —. - �— --- Number 1 �— <br /> SUMPS ❑ Distance to nearest: Wella Foundation 40 Property Line—� <br /> DISPOSAL PONDS f] <br /> I 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquih countyrmit is issued, I shall not <br /> ordinances, state laws, and <br /> I rules and regulations of the San Joaquin Local Health�District. <br /> Home owner or licensed agent's signature certifiAs'the_following:_'I certify that-in tha performance of the work for which this pe <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in issued, I shall employ persons subject to workman's compensa <br /> the performance of the work for which this permit is <br /> tion laws of Calilomia." L.. ., <br /> The applicant t call for required- pections. Complete drawing on rover a side. t <br /> Date: _ <br /> Signed Title. 4 <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by <br /> 1 Date Final inspection- 9. 1 ' Date <br /> t Pit or Grout Inspection by <br /> Additional Comments: <br /> O Stk 466-6781 F-1Lodi369-3621 C] Manteca SM-7104 ❑Tracy 835 6385 <br /> 1[i41 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services <br /> FEECASH K RECEIVED BY DATE PERMIT NO.,' <br /> )NFO AMOUNT DUE AMOUNT REMITTED <br /> F •. zy <br /> EH13.241REV.)/A5 - �a. 7Te]"' tJ � <br /> EH 14.26 <br />