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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 ' <br /> PERMIT EXPIRES TYEAR 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 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 0 �_ $ ^ y Lot SrzCite� � PM <br /> f Phone ` <br /> I Owner's Name Address& 14_ <br /> hContractor Address a License No.� � Phone �� ✓ <br /> MTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrialj ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LlDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public { ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> J I Irrigation 1 Approx, Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 1 El Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth I Filler Material {Below 501 'T <br /> " 'TYPCOF. SEPTIC WORK: NEW INSTALLATION i s REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> s S available within 200 feet.) ` ^,L <br /> Installation <br /> s�will serve: Residence Commercial_ Other <br /> i Numberl6f living units: __L_ Number o bedrooms.-3-- ! (may <br /> Character of soil io a depth of 3 feet: 0 "e+f- Water table depth K r } <br /> SEPTIC TANK I CL-qype/Mfg Ca ity IAa No. Compartments <br /> PKG. TREATMENTiPLT. ❑ _L}-,C�� Method of Disposal l-- <br /> I Distance to nearest: Wellf faunda�ion Property Line <br /> l LEACHING LINE CI--'No. & Length of lines L3 V46 M, T ta`lengthksize ^ -6 i t <br /> FILTER BED ❑ Distancetto nearest: Well 110 I Foundation ::)w­}_`'Property Line /50 I <br /> nt 1 �a �r Number <br /> SEEPAGE PITS Depth Size <br /> C SUMPS Cl Distance to nearest: Well Foundation ,.30(_.� Property-Line' L__20 1 <br /> r1! r t <br /> DISPOSAL PONDS] ❑ <br /> i 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 /> t certifies the fallowing: "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 Califorhia." I <br /> rk The applicant must'call for all req ed ' spections. Complete drawing on reverse side. I <br /> Signed X ii Title: "J.f// A Date: <br /> 1 FOR DEPARTMENT USE ONLY �i�_ } <br /> Application Accepted by Date w Area <br /> r <br /> /PiYor Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: 1y f <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104'" " ❑ Tracy 1835-6385' <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.—Box 2009, Stk., CA 95201 <br /> f <br /> r FEE AMOUNT DUE AMOUNT REMITTED CK 9 RECEIVED BY DATE PERMIT'NO. <br /> INFO ICASH <br /> +.EH13-241REV.rinse "� �� � � " Iof <br /> r EH 1426 <br />