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j APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZELTON AVE., STOCKTON, CA P� <br /> Telephone (209) 466-6781 t <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 /> f 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 /> I. Job Address / /l ,( City Lot Size PM <br /> i QQ <br /> Owners NameSCJ�?31�% Address Phone /I _ <br /> Contractor's Name - License No.L <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS` `(' <br /> ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal .Type of Grout p <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair it Work Done ❑ Type of Pump H.P. ". State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 509 - <br /> Depth I Filler Material (Below 509 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence jef—Commercial_ Other <br /> Number of living units: 4-- Number of bedd oms y <br /> Character of soil to a depth of 3 feet: Cz e l- �G?` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _� Capacity�� No. Compartments 491 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal y <br /> Distance to nearest: Well 10— Foundation 1/��... ,.'Property Line a <br /> LEACHING LINE (S�No. ' Length of lines � � I f Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS °'Y Depth. _oI Size =/ Number <br /> SUMPS ❑ Distance to nearest: Well // h— Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I have prepared this application and that the work willbedone in ac0,oidance 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."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." <br /> Theapplicant. ust 11 for all ui ` spections. Com etedrawin on re side. <br /> Signed X Title. <br /> /Gf` '�j' Date: <br /> FOR A ENT USE ONLY <br /> Application Accepted by �� Date J ree <br /> Pit or Grout Inspection by Date / r W0 Final Inspeci/on by Dee <br /> //- , Dee <br /> Additional Comments: 44W �//�G'iS qF o-0/ ! ' • <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 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> ♦EN 10.24(REV.10/831 <br /> EH 25 1��✓JJ— � <br />