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!i <br /> II <br /> II APPLICATION FOR PERMIT <br /> �l SAN JOAQUIN LOCAL'S HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 4fi6-6781 <br /> II PERMIT EXPIRES 1 YEAR FROM DATE 'ISSUED; <br /> 1 L.' <br /> (Complete in Triplicate) , <br /> `'�'Rur tart. r . ^'!L • ;-:' •.0 <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 /> h <br /> Job Address CityG .___. Lot Size PM <br /> Owner's Name LAJ Address' Phone - <br /> Contractor Address �d/ / �-� License N14_2tQM�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT U DESTRUCTION ❑,f e' <br /> PUMP INSTALLATION`S T \_,, SYS TEM REPAIR ❑ r� OTHER 11 <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWEW4ANES�' �' DISPOSAL/FLD.____. .PROP. LINE <br /> r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> + INTENDED USE _.TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> U Industrial" ' O Open Bottom ❑ Manteca Dia. of Well Excavation"` Dia. o{Well Caging <br /> Eb Domestic/Private (- Gravel Pack L1 Tracy Type of Casing 4=.; Specifications -i <br /> C 1Public L. Other it _1 Delta Depth of Grout Seal f Type of Grout <br /> Itrigation ---Approx. Depth -1 Eastern Surface Seal Installed <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well bestruction Well Diameter ___..._ Sealing Material (top 501-� J 4- ; <br /> Depthl II Filler Material iBelow 5(Y) <br /> TYPE OF SEPTIC:WORK: -NEW INSTALLATION REPAIR/ADDIT40N ❑ DESTRUCTION ❑ (No septic,system'permitted if public sewer is <br /> 'uvailable within 200 feet.) <br /> Installation will serve: --Residence' Commercial-��• Other..'-- ; ;-�.• ar�.y ''i - .. '" <br /> Number of living units: ___ Number of bedrooms %1 :,.ra J l. <br /> Character of soil to a depth of 3 feet: Water table <br /> SEPTIC TANK 1. Type/Mfg Capacity ^ No. Compartments ' <br /> PKG. TREATMENT PLT. F_ - Method of Disposal <br /> Distance to nearest: Well Foundation- 0 Property Line <br /> LEACHING LINE l c. & Length of lines .U- —:- Total length/size <br /> FILTER BED vDistance!to nearest: W/elle/ Foundation s�6 Pi Property Line <br /> 1 <br /> SEEPAGE PITS ❑ ^Depth % ( ' Size � ! " f Number }` , <br /> SUMPS r ❑ Distance to near Well Foundation + Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this applicaiion and that the work wiil.be done in accordance with San Joaquin county ordinanc$s, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certif4s 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 Califomia." Contractor's hiring or,6u �`` ntracting signature <br /> certifies the folbwing: "I'certify that in the performance of the work for which this permit is issued, I shall employ persons subject to;Arkrrlan's compensa <br /> tion laws of California." Ij Nr� <br /> The applicant must call for.all uired: spectio Complete drawing on reverse side. <br /> Signed XTitle: s�tr�l t 1 Date: <br /> i� FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Pit or Grout Inspection by ' __— Date_ Final Inspection by Date ,J <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant - Return all copies to: Environmemat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> lid i <br /> FEE AMOUNT DUE, _ AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-244nEV.i's5: <br /> EH 14-28 <br />