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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1801 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 ��� <br />' PERMIT EXPIRES 11-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r <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 /> /XQ�E <br /> Owner's NameJ14C I Address �� GLI/O/°L_'6Z/AS Wd'y5/ � Phone 3f <br /> Contractor.�f <br /> Address License.No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 'O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TIC TANK SEWER LINES DISP PROP. LINE <br /> FOUNDATION RICULTURE W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROS A CON SPECIFICATEONS 1 �" <br /> L7 Industrial- ❑ Open Botto Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Pack ❑ Tracy Type of Casing S "fications <br /> ❑ Public ❑ Other 1 f7 Delta Depth of Grout Seal Type of Grou _ <br /> I I Irrigation --Approx. Depth I I Eastern. Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done ( V <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION I,I DESTRUCTIO INo septic sysiem permitted if public sewer is <br /> '}} vailable within 200 feet.) <br /> Installation will-serve: Residence T1 Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK Cl Type/M?g Capacity _ No. Compartments . <br /> PKG. TREATMENT PLT. ❑ k1 Method of Disposal <br /> Distance'to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size JJJ <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size <br /> Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line i <br /> DISPOSAL PONDS ❑ <br /> 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 tv become subject to workman's compensation laws of California."�C&tf at'turls hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 11 <br /> The applicant must all for all req in do omplete drawing on reverse side. <br /> f <br /> �JJ\ Signed Title: N Date: <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> " Application Accepted by A JDate �2 � Area 0 <br /> DA r <br /> Pit or Grout Inspection Date Final Insp c i �s�..�c�`�• <br /> on by s st to ` <br /> r-- , cs.�sS <br /> Additional Comments: " <br /> ❑ Stk- 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <br /> Applicant- Return all copies to: Environmentat Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO J� SH RECEIVED BY jDATE PERMIT NO. <br /> a.EM 14-21tREY.,I/n51 1 �S -IEH 11-26 1ff p US( <br />