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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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 /> 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 /> Job Address 9 O City Lot Size PM <br /> Owner's Name AeZZvt! Address .r��4 Phone /+Sro9 <br /> Contractor 4LAAA tte.rc1-.se.uJ Address .3940/V. License No. Phone 4 <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 OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f`7 Public f:! Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth „-_ Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION tNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence j_�fl Commercial X Other <br /> Number of living units: Number of bedrooms le <br /> Characterof soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK A Type/Mfg 4— e o cot 'ft Capacity /,1 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation' ) ..-- Property-Line <br /> . t <br /> LEACHING LINE 41' No. & Length of lines �d6 / Total length/size <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth S/ __Size Numbers_ <br /> SUMPS 0 Distance to nearest: Well 1110-4- Foundation i _ Property tine S/� I <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, 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> ! <br /> Signed X 42�1 Title: G a - _ Date:ri <br /> �40R DEPARTMENT USE ONLY �# <br /> Application Accepted by pate o Area <br /> Pit or Grout Inspection by w Date Final Inspection by ate �'�� ►'� <br /> Additional Comments: i <br /> ❑ Stk 466-6781 Ct Lodi 3659-36211 ❑ anteca a2 -7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2 5069 tk., CA 95201 <br /> k <br /> INFO AMFEE OUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. i-E <br /> w <br /> a EH 13-24{REV.i i a 51 I � -EH 14-26 <br />