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r <br /> APPLICATION FOR PERMIT ry <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (205) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> p hcation is <br /> Application is hereby made to theh"San Joaquin Local Health District fora permit to construct and/or install the work herein described. This app' f <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 /> - <br /> _ City Lot Size PM <br /> Job Address <br /> I <br /> Owner's Name (�° 1(/I n Address �Q Phone <br /> \ _ <br /> Contractor <br /> ! Phone <br /> Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ED REPLACEMENT ❑ DESTRUCTION 171 <br /> PUMP INSTALLATION C3T SYSTEM REPAIR ❑ OTHER El <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing , t <br /> ' <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation i <br /> Type of Casing Specifications <br /> ❑-Domestic/Private El Gravel.Pack ❑ Tracy Type of Grout <br /> FI Public Other ❑ Delta Depth of Grout Seal — <br /> Ll i <br /> I 1 Irrigation -Approx. Depth l"1 Eastern Surface"Seal installed-by- 4 "— <br /> ¢ H P State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Wets-Diameter Sealing Material (top 50') <br /> Depth Filler Material (Bel 50'1 " <br /> r 4' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION •I ' DESTRUCTION 1 I anvailablelwi within 200 feec system t.) ewer is <br /> F Installation will serve: Resi11ence :�//Commercial— Other <br /> Number of living units: �;'!__ Number of bed ooms 3 ` <br /> i f C�4.�1 Water table depth <br /> Character of soil to a dept ,of 3 feet? <br /> Te/Mf Capacity i"—ro m — No»£ompartments <br /> SEPTIC TANK �tYP 9 Method of Dispotsal <br /> PKG, TREATMENT PLT. <br /> L1r <br /> Distance to nearest: Well Foundation Property Line" <br /> <' LEACHING LINE No. & Length.of lines 4 <br /> dotal length/size <br /> Foundation___ � Property,Line <br /> FILTER BED (_1 Distance to nearest:"' Well <br /> De tit qumber <br /> SEEPAGE PITS ""` p Size <br /> LZ "Distance 6_nnearest: Well es Foundation Property Line <br /> SUMPS � <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 Diltrict. <br /> t's signature certifies the following: "I certify.that in the performance of the work for which this permit is issued, I shall not <br /> Home owner•or licensed agen <br /> employ any person in such manner as to became subject to workman's compensation laws of Califotnia.," Contractor's hiring or sub-contracting signature <br /> certifies the following.."I certii`y that in the performance of the work for which his permit is issued, I shag employ persons subject to work n's compensa- <br /> tion laws of California." 9 ~ <br /> The applicant must ca for all re ulre inspections. Complete drawing on reverse side. 176 f Date: <br /> Signed;X ?" <br /> F DE T USE ONLY <br /> Dab�y <br /> Area <br /> Application Accepted by —.. t, <br /> � Dat <br /> /Piflor Grout Inspection by _ Date Fina! Inspection <br /> I�I r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6365 <br /> Applicant - Return all copieslto: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,-Stk., CA 95201 <br /> I� <br /> FEE AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13-241REV.t <br /> E EH 14-28 <br />