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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA f <br /> Telephone (209) 466-6781 <br /> ( PERMIT EXPIRES TYEAR 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. <br /> �,?/ -? `.�/�'iS� .�. !� City s 'lay Lot Size PM <br /> Job Address <br /> I ( /taw J Address J r34�o rf✓ Aj � Phone 0- <br /> Owner's Name <br /> �/t!$d Address �! License No. Phone <br /> Contractor <br /> I� TYPE OF WELL/PUMP: NEW WELL L3 WELL REPLACEMENT L1 DESTRUCTION ❑ <br /> PUMP INSTALLATION LJ SYSTEM REPAIR EJOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L] Industrial El Open Bottom L) Manteca Dia. of Well Excavation <br /> Specifications <br /> C Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Type of Grout—. - <br /> E` ° F1 Delta Depth of Grout Seal <br /> {`l Public ❑ Other r <br /> f I I Irrigation -Approx. Depth 11 Eastern <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H,P. <br /> State Work Done <br /> Sealing Material (top 50'1 <br /> ❑ — <br /> Well Destruction Well Diameter <br /> 9 <br /> Depth Filler Material (Below 501 W <br /> 4 TYPE OF SEPTIC WORK: NEW INSTALLATION L:1 REPAIR/ADDITION l I DESTRUCTION (Nc septic system permitted if public sewer is <br /> I k available within 200-feet.) -- —4 <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedroom <br /> Water table depth <br /> i Character of soil to a depth of 3 feet: <br /> ►�.t 41 k Capacity" ""'llln. Compartments. r <br /> SEPTIC TANK 1111i< Type/Mfg t { <br /> l PKG. TREATMENT PLT. ❑ r Method of disposal <br /> Distance to nearest: Well ..Foundation Property Line t � <br /> ' ( Total lengthlsize <br /> i LEACHING LINE El No. & Length of lines { <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> } 1 <br /> —.__i # r. <br /> SEEPAGE PITS l 1 Depth Size — Number { <br /> I SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> cordance with San Joaquin county ordinances, state laws, and <br /> I hereby,certify that I have prepared this application and that the work will be done in ac <br /> rules and regulations of the San Joaquin Local Health Oi'trict. <br /> Home owner or licensed agent's signature certifies the following:.,�l 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 workniah'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 /> The applicant mu t call for all a uired inspections. Complete drawing on reverse side. p <br /> Signed X Title: ' <br /> Date: of �S�S <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Date �✓ Area <br /> Application Accepted byry <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date O <br /> F Additional Comments: ` <br /> ❑ Stk 466-6781 1-1Lodi 36e3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> r Applicant - Return all copies to: Environmental Health Permit/Servicos 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 0 <br /> -- y--�- EEE - AMOUNT-Dt)E-- "AMOUNT REMITTED CEK � RECEIVED 6-Y DATE PERMIT-NO. <br /> INFO i <br /> + EH 13-Z4 iREV.!i n 51 <br /> EH 14.28 <br />