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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 71 10 -1, .,r3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �..� <br /> (Complete in Triplicate) l� a� <br /> f <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 welt/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District., <br /> Job Address Rd Cid` of Size PM <br /> Owner's Name "`'A�dress <br /> .S� I" �` Phho e- �dZ2o <br /> Contractor's Name icense N' Phone. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> v,4 I <br /> DISTANCE TO NEAREST: SEPTIC TANK -'\' SEWER LINES DISPOSAL FLO. PROP, LINE . <br /> FOUNDATION., ~ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom D Manteca• —� Dia:of,Well'Ex_cavation Dia. of Well Casing, <br /> T e of Casing- <br /> 1-1 <br /> asin` Specifications s <br /> ❑ Domestic/Private El Gravel Pack El Tracy Type 9 <br /> ❑ Public ❑ Other.'g ❑ DDel+taf Depth;of Grout Seal Type of Grout <br /> .,� 01 <br /> ❑ Irrigation �pprox.Depth ❑ Eastern 'Su�Face Seal Installed by <br /> Repair Work Done El Type of Pump w" H.P. State Work Done <br /> Well Destruction ❑ Well Diameter i Sealing Material (top 501 k <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION El 'DESTRUCTION Ll (No septic system permitt' if public sewer is <br /> -- - - 1 available within 200 feet.ie � s <br /> Installation will serve: Residence-- Commercial _Other „ <br /> Number of living units: Number 6J.bedrooms_ � s. +. <br /> Character of soil to a depth of 3 feet: ""` Water table depth {� <br /> SEPTIC TANK (yType/Mfg i?. Capacity - /No. Compartments <br /> { <br /> PKG. TREATMENT PLT. ❑ ; �. *N AMethod of Disposal i <br /> " Distance toBarest."—We-ll--''o i Foundation 1/2 Property Line Q� `y- <br /> . <br /> LEACHING LINE &---No. & Length of lines To Iep gth/size [,JC <br /> a% ��� ''' Pro Line <br /> FILTER BED �istance to nearest: Well" G Foundation pe+h+ —6 �— <br /> SEEPAGE PITS e—,Depth "� -Size Number <br /> SUMPS ❑ Distance to nearest: Well Z Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> 1 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 of the work for which this permit is issued,I shall employ persons subject to workman's compensa- i <br /> tion laws of California." , <br /> The applicant ust call for I re uired inspection . Complete drawing on reverse side. <br /> Signed Title: p� Date: . 0 <br /> FQ DEPARTMENT USE ONL <br /> // "` :.k.�•`� `=�. Date 'r Area <br /> Application Accepted by <br /> `l , ::,• _. _ <br /> Pi r Grout Inspection by ! J`--�' ate ` '��Final Inspection by 4,,-t ��� <br /> k Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3511 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 200x, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> +EH 13-21(REV.101831 - 1� <br /> I EH W28 - - - <br />