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0 <br /> 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 1 YEAR FROM DATE ISSUED <br /> 19 " (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 J'baquin 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 /> lifj: <br /> Job Address �Cfi �f Cit Lot Siz r'"" PM <br /> z <br /> Owner'skNametj�& Address Phone <br /> Contraces License No_,— <br /> Phon `c. <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C3SYSTEM REPAIR O-THER--Cl'-_ - <br /> ,DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br />{ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> I <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing j t <br /> ❑ Domestic/Private ❑FGravei Pack ❑ Tracy. Type of Casing """"� Specifications <br /> M Public ❑Other ❑ Delta r , ; ` Depth of..Grout Seal' Type of Grout _ <br /> I I Irrigation �P .Approx. Depth I Eastern Surface So I Installed by <br /> t '"Repair Vlfoik'Done ❑ Type of Pump H`P` r �_. -- Stati;'Work Done?-_ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth ` Filler Material (Below 501 <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence.'!� Commercial /Other <br /> G ��; <br /> Number of living units: -f- - Numb*rdam _��"7 — /1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> LJ . <br /> SEPTIC TANK X �TypelMfg Capacity .__-- Na' Compartments rn <br /> PKG. TREATMENT PLT. ❑ II' Method of D'sposal <br /> 9 Foundation� Property Line <br /> Distance to nearest: Well " <br /> LEACHING LINE No. & Length of lines d ` ��F. dotal length/size X <br /> FILTER BED ❑ !�Distance to nearest: Well._-� Foundation's//� Property Line _-,_._ <br /> Id t i r� <br /> SEEPAGE PITS Depth _ i95 Size � �� `�` Number � <br /> SUMP$ L1 'I Distance to nearest: Well Foundation= Property-Line <br /> DISPOSAL PONDS ❑-� � � / � <br /> I hereby certify that I have prepared this application and that the work will tie done.inFaccordance with.}San Joaquin county ordinances, state laws, and <br /> ' rules and regulations of the San Joaquin Local Health Di§trict. F' <br /> Horne 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 Jaws 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- <br /> tion laws of California." ! <br /> The applicant must c for all' uired inspections. Complete drawing on revers <br /> Signed Title: y` f Date: <br /> i <br /> FOR DEPARTMENT USE ONLY A � <br /> Application Accepted byDate ' Area <br /> I . <br /> k <br /> �or Grout Inspection by Datef,O� Final Inspection by <br /> .i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> f 9 <br /> +.EH 13-24(REV.i/)15) II � r-9,F- <br /> EH 14-26 <br /> 11 <br />