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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1.' 1601 E. HAZE,TON AVE., STOCKTON, CA <br /> ;..., Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ;b. 4 <br /> Application is hereby made to the San Jbaquin Local Health District for a permit to construct and/or install the work herein described.This applrcatfon is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weNlpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. - <br /> y� <br /> Lot SIZE <br /> Job Address V� <br /> r Address Phone <br /> Owner's Name - <br /> [�- J�License IVo. 0 * �Phone��-'4r" <br /> Contractor Address <br /> TYPE OF <br /> AM <br /> P: NEW WELL ❑ WELL REPLACEMENT ❑' DESTRUCTION ❑ ' . <br /> h ' <br /> PUMP INSTALLATION C3. <br /> -' <br /> SYSTEM REPAIR'❑'�� `,,x "l a OTHER ❑ <br /> DISPOSAL FLD. -f---PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PITS/SUMPS <br /> FOUNDATION 4,^ OTHER WELL <br /> AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> { Dia. of Well Casing <br /> ❑ Industrial,, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation � , <br /> T of Casin l Specifications <br /> ❑ DomesticfPrivate ❑ Gravel Pack ❑ Tracy YF Casing— <br /> 0 . <br /> ❑ Other ❑"Delta Depth of Grout Seal Type of Grout <br /> ❑ Public + <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by '., . <br /> Repair Work Done ❑ Type of Pump l H.Pn� " '' .State Work Done <br /> r Sealing Material (top btl') <br /> Well Destruction ❑ Well Diameter � -� g „�,,,_ � <br /> Depth - % Filler Material (Below 50'}fl <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITIONi =DESTRUCTION ❑-.available septic <br /> Syitem permitted if public sewer is <br /> Installation will serve: Residence feet <br /> Commercial Other i' <br /> e � ` d <br /> i� Number of living units:� Number of bedr000ms ' Water tabI depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> Capacity_ <br /> SEPTIC TANK ❑ Type/Mfg ��'" .Method of Disposal <br /> i PKG. TREATMENT PLT. ❑ 4st , <br /> # Distance to nearest: Well ''zFoundation Property-Line <br /> J� <br /> No, & Len Length of lines Total length/size— <br /> LEACHING LINE g Property Line <br /> FILTER BtD + � "Distance to nearest: Well Foundation <br /> C . �'� Size Number <br /> f SEEPAGE PITS C1 Depth 6 p- <br /> SUMPS .°5-106istance"to nearest; Well .—�.Faundationr Property Line <br /> = DISPOSAL PONDSstate laws, and <br /> ❑ �' ' <br /> I hereby certify that I have prepared this application and that the work wilt-be done in accordance with San Joaquin county ordinances, <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 /> cmplo s the following: u certify that s o bece. ome <br /> su performance of the work for which this permit is issued,I shall employ persons subject to workman's corrfpensa- <br /> r tion laws of California." + <br /> jThe ap licant ust cal red inspections. Complete/drawing on reverse side. <br /> ,rte Title: Dater <br /> i Signed <br /> - FOR DEPARTMENT USE ONLY <br /> [ Date Area <br /> ft <br /> Application Accepted by L <br /> �?/ Date Final Inspection by Date <br /> Pit 6 r u -nspection by <br /> l Additional Comments: ~' <br /> ❑ Stk 466-6781 Lodi 369-3621 ElManteca 823-7104 ❑Tracy 835.8385 <br /> Applicant- Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> y <br /> FEE AMOUNt DUE -AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. <br /> INFO <br /> r + EH 13-241FIEV-1/951 <br /> EH W26 l <br />