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�i <br /> APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTS, <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) k�`. <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 /> � <br /> Job Address T City Lot Size PM <br /> Owner's NameAddress Phone 44 <br /> l �,�, <br /> Contractor Address— 1� A Le+/—& ! Phon <br /> License N : <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑? SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISP PROP- LINE <br /> EL <br /> FOUNDATION AGRICULTURE WL OTHER WELL PITS/SUMPS <br /> iNTENDfD USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS, <br /> ❑ Industrial ❑ Open Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> l•l Public 1 1 Other M Delta Depth of Grout Seal Type of Grout <br /> k, <br /> I i Irngatian pprox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destru ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') s <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION Il REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is <br /> —' r" - available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> s <br /> Number of living units: Number of bedrooms <br /> Character.of soil to a depth of 3 feet: Water-table depth <br /> ' SEPTIC TANK ❑ T e/Mf r <br /> YP 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well s Foundation Property Line <br /> LEACHING LINE ❑ No'& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation r. 1 Property Line <br /> SEEPAGE PITS I I Depth Size k. Number <br /> SUMPS ❑ Distance to nearest: Well I Foundation Property Line k <br /> DISPOSAL PONDS ❑ ; �+-• ^—� a — <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, I shalt not <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: "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 /> lion laws of California." <br /> The applicant'Ast call for all required ins pe tions. Complete drawing onre arse side <br /> Signed X r Title: Y Date: � <br /> IJ �� <br /> FOR QF.J2i4ATMENT USE ONLY <br /> Application Accepted by '--� �— —�� c �7 <br /> Date �'"� 1 Area <br /> 03P A— <br /> Pit or Grout Inspection by i Date ( Final Inspection by Date <br /> Additional Comments: E <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ ik,%IiAteca 623-7104 ❑ 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 /> 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT NO. 3 <br /> *-EH 13-211REV.1/k51 ����� ��� �� _ 231 <br />