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I! APPLICATION FOR PERMIT <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 /> n (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 City Lot Size PM <br /> 4405-40646 <br /> 3S3a/ <br /> Owner's Name �� � � Address � Nip&opPhone <br /> Contract �� Address 4 GS� <br /> License No i Phone_ <br /> TYPE OF WELL/PUMP: it 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 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ID Tracy Yp 9 Trac T e of Casing s <br /> Specifications <br /> FPublic ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth € I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material /top 50') `;..I 0 <br /> Depth I� Filler Material (Below ') �^r`j _ <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION I 1 REPAIR/ADDITIONESTRUCTION i I (No septic system permitted if public sewer-is <br /> I available within 200 feet.) �Q <br /> Installation will serve: Residence Commercial Other p, <br /> Number of living units: ._ Number of bedrooms 4 <br /> Character of soil to a depth of 3 feet: r Water table depth !!! <br /> SEPTIC TANK ❑ Type/Mfg Ca acit j <br /> a <br /> Capacity— No. Compartments tf <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation wm Property Line _ <br /> LEACHING LINE No"'& Length of lines IE Total length/size 3 <br /> FILTER BED ❑ Distance to nearest: WelttFAt1 I / Foundation Property Line <br /> u _ <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well <br /> II Foundation Property Line <br /> DISPOSAL PONDS ❑ v } <br /> I hereby certify that I have prepardd 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 Di§trict. <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 ins h manner�as to become biect <br /> certifies he : i to workman's compensation laws of California:"'Contractor's-hiring'or sub-contracting signature <br /> • tfollowingcertify that in the pert nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Califo i »� <br /> The appli nt st II for all require ns ctions. Co ete ing on reverse side. <br /> i <br /> Signed X ail-. . t' <br /> ,Title: tr i <br /> Date: <br /> FOR DEPARTMENTtUSE ONLY <br /> E' `k <br /> Application Accepted by 1 DateArea '} <br /> Pit or Grout inspection by Date Final Inspection by ' Date <br /> Additional Comments: — y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 I❑ Tracy-8356385"'""" I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT-NO. <br /> +.EH 13-24 iREV.1/H ss .I� <br /> EH 14-26 1 1 _ a <br /> i 7 I <br />