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I APPLICATION FOR PERMIT <br /> k <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 Nn.549 for-'sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />{ Local Health District. �J`uI <br /> Job Address f j '&� Cit, Lot Size Z011-e— <br /> V PM <br /> Owner's Name Address 7 )-( T / / <br /> Phone <br />[ Contractor's NameLicense No. �� Phone <br /> `�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private El Gravel Pack- ❑ Tracy Type of Casing Specifications i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout SeaiEE <br /> ❑ Irrigation _A Type of Grout t <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump 1 H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is \J\ <br /> / _ available within 200 feet.) <br /> Installation will serve: Residence� f Commercial_ Other � � f <br /> Number of living units:__.� Number of rooms <br /> Character of soil to a depth of 3 feet: A fes. I I <br /> SEPTIC TANK L�Type/Mfg L' Water table depth <br /> cCapacity� No. Compartments 2r i <br /> PKG. TREATMENT PLT. ❑ . <br /> Method of Disposal <br /> Distance to nearest: Well 100'_ Foundation 10 r Property Line1,261 I <br /> LEACHING LINE No. & Length of lines O / <br /> Total length/size <br /> FILTER BED El Distance to earest: Well�A.3101 Foundation_ �{�r Property Line <br /> SEEPAGE PITS El--Depth _,2LS ` Size: <br /> Number_ <br /> SUMPS ❑ Distance to nearest: Well 0 Foundation , <br /> DISPOSAL PONDS ❑ _ 1,7 �._ Property Line <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 o'f.the work forywhich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ­.—t <br /> The applicant must call for qui ed inspections. Complete drawing on'reverse side:- <br /> . i �. F <br /> Signed <br /> Title: L Date: 'X <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted by bate W � ` <br /> Area C1 _ <br /> Pi or Grout Inspection by �_ `� toinal Inspection byx�` <br /> Additional Comments: <br /> ❑ Stk 466-6781 _ ❑ Lodi 369-3621 D Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmerita! Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009,'Stk., CA-95201 <br /> _ A <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH•' RECEIVED BY DATE PERMIT"No. <br /> +EH 13-24IREV.101831 7b* Op c�i$f {�7 <br /> EH 14-26 ✓ �o J <br />