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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT ON AVE., STOCKTON, CA <br /> Telephidne (209) 466-6781 �1) <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> {Complete in'Triplicate)" U_ <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 /> , <br /> , <br /> Local Health District. <br /> Lot S'iz'e` W:i�� PM <br /> Job Address AV'.. City <br /> a. <br /> Phone' <br /> Owner's Address go <br /> EDO <br /> Phone�A <br /> Address License NO2&J 19_Ca <br /> Contract <br /> NEW WELL F-1 WELL REPLACEMENT LJ DESTRUCTION LJ <br /> TYPE OF WELL/PUMP: <br /> SYSTEM REPAIR El OTHER 0 <br /> PUMP INSTALLATION F DISPOSAL FLD,_ PROP. LINE <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE. TYPE OF ELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSDia..of Well Casing <br /> Bottom ❑13—Manteca Dia, of ell Excavation <br /> 0 Industrial El Open Bo Specifications <br /> 0 Domestic/Private "U0 Gravel Pack,, El Tracy Type Or Casing Type of Grout <br /> ❑ Public 0,,Olh., ' F1 <br /> A - Delta Depth of Grout Seal <br /> 1 <br /> 7 Irrigatio Depth L1 Eastern Surface Seal Installed by <br /> n __L%pprox. <br /> Repair Work Done _/N State Work Done <br /> Type of Pun H <br /> Well Destruction ❑ ;,Well Diameter — Sealing Material ftopim') <br /> )ler Material i8elow 501 <br /> J,Deo_ <br /> TT`PEOF SEPTIC WORK: NEW INST=T1I0N ET DDITION Er—,DESTRUCTION I-] (No available septicwithin syste200 fm peeet.)rmitted if public sewer is <br /> Installation ill— <br /> serve: <br /> Rdenw:� the, <br /> Number of living units: Number' edroono <br /> i C ­ Water table depth <br /> Character" of soil to a depth of 3 feet- <br /> Capacity— No. Compartments <br /> SEPTIC TANK Type/Mfg -,� \ `�—, - <br /> 1_/ I I Method of Disposal <br /> PKG—. TREATMENT PLT. L I <br /> —Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE -T1EI.,,No &.: Length of.lines <br /> 0- Distance nearest: Well Foundation Property Line <br /> FILTER BED <br /> S.,z Number <br /> SEEPAGE PITS 2" Depth a-5 Size 1�, Property 4 e 10" Prope <br /> SUMPS fi Cl Distance to nearest: Well /412t)L <br /> FoundationSSALIPONDS <br /> DI RO county ordinances, state laws, and <br /> ion and that,the work will be done in accordance with San Joaquin <br /> I hereby cei�ify-ihat'l ha�e prepared this-applicat <br /> S <br /> rules and regulations bf'the an Joaqdin Local Health District. <br /> certifies the following: "I certify in the performance of the work for which this permit is issued, I shall not <br /> Ho�pe owner or licensed agent's signature -contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub ' <br /> certifies the1f0_H6w_in_g_:"I certify that <br /> in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tlon,Iaws of California.", <br /> The.aof-Alcant st call for all equir-d inspections. Complete drawing on reve <br /> -2 00's <br /> Date:, <br /> Signed V C/ <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> Application I Accepted by Final Inspection by <br /> it�o r oult inspection by <br /> epfllA/ <br /> Additional Comments: -3621 7-1 Manteca 823-7104 0 Tracy 83545385 17 - <br /> 0 Stk 466-6781 0 Lodi 369 - <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 'NO.' <br /> FEE CK# RECEIVED BY DATE PERMIT <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> +EH 13-24(REV.1/a 57 <br /> EH 14-25 <br />