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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i 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. f <br /> Job Address Z Z 0 S 1e.e Lh City n Lot Size 7S x `� PM <br /> Hy.i 1n ?-2-D -S Lt 1 cx L ke.- LN Phone gu&�U 0 41 <br /> Owner's Name �S h �.d �CZ. Address <br /> tl Contractor Address ZZ C� 5 t-c�r�IIGC�� t"� License No. Phone <br /> r <br /> G TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT l❑ DESTRUCTION ❑ <br /> PUMP INSTALION El SYSTEM REPAIR El OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. PROP. LINE <br /> NT, <br /> t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL AREA STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ cy Type of Casing Specifications <br /> I'! Public ❑ Other Delta epth of Grout Seal Type of Grout ._ <br /> I 1 Irrigation __.Approx. pth I I Eastern Su a Seal Installed by _ <br /> Repair Work Done ❑ Type of P mp H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1'1 REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence I Commercial— Other <br /> Number of living units: Number of bedrooms Q� <br /> Character of soil to a depth of 3 feet:# Water table depth 1O <br /> SEPTIC TANK ❑ Type/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> to <br /> LEACHING LINE ❑ No. & Length of lines Total length/size U <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ 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, 1 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-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." ID <br /> The applicant must.call for all requiredLlpect. <br /> ons. Complete drawing on reverse side. <br /> Signed X Title: n 9— Date: <br /> FOR DEPARTMENT USE ONLY �f+� <br /> Application Accepted by V" L Date �Q ~ Area \v L.J <br /> Pit or Grout Inspection by Date Final Inspection by Date �f , <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE <br /> AMOUNT REMITTED CK if RECEIVED BY DATE �j PEERMIIT'NO. <br /> +.EH t14-29 3-24{AEV. <br /> EH 1/9 5) C 50 �• "'� 11 / !, -73A <br /> f <br />