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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 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.t, �q r ;'. A^S.>� J <br /> Job Address City .S��'/� . _ :Lot Size,�Q ,1 — PM <br /> .- <br /> Owner's Name �J ' ./LC-� � Address r Phone <br /> Contractor's Name �/�2F�/J'/7 21 X 9!E�C License No. __ i�' .�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL:-❑• w WELL REPLACEMENT ❑ DESTRUCTION.-El <br /> PUMP_INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK t SEWER`LINES` " ' ` - DISPOSAL FLD. I PROP-. LINE; <br /> I FOUNDATION_: AGRICULTURE WELL ` OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONSPECIFICATIONS <br /> ❑ Industrial I ❑ Open Bottom ❑ Manteca Dia. of Well•Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> E] Public ❑ Other Delta Depth of Grout"`Seal Type 01 ; <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done f F <br /> Well Destruction 10 Well Diameter Sealing Material (top 501 <br /> i. Depth Material (Belo ') f 1^ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAI DDITION ~DESTRUCTION' El (No septic system permitted if public sewer is V} <br /> r i - " y' available within 200 feet.) <br /> Installation will serve: Residence ✓Commercial_ Other <br /> Number of living units:,—,/— Number of bedrooms 7— <br /> Character of soil to a depth of 3 feet: Water table depth d <br /> SEPTIC TANK ; 4 Type/Mfg Capacity No. Compartments,! <br /> Method of Disposal /,r- <br /> PKG. TREATMENT PLT.+❑ ` r. $ g <br /> 1—Distancerto-nearest:­Well tY�=Foundation Property-Line <br /> a <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> c <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line { <br /> I f <br /> SEEPAGE PITS ❑ Depth, Size Number I <br /> SUMPS ❑ Distance to nearest: Well Foundation 'Property Line i <br /> DISPOSAL PONDS+ ❑ ' ' J <br /> I hereby certify that l 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 Calfornia." <br /> The applicant t call for all required inspections. Complete drawing on reverse side. <br /> Signed X +1 Title: Date: <br /> I FOR DEPARTMENT 115E ONLY <br /> Application Accepted by �^ - -s7%j� Date Area 03 <br /> Pit or Grout Inspection by -� g Date `Final Inspection by -- ^� � �^^�+�� Date -Additional Comments: <br /> Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Mariteca' 8:3-7104•x% ❑ 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 CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO `` <br /> + EH 13-24 IREV.101831 L �/7 g• �� ` <br /> EH 14-28 —{ <br /> I I <br />