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F <br /> 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 /> (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 /> r p� <br /> Job Address r`Q 5 d # City�'"a Lot Size PM <br /> r: � h <br /> Owner's Name ��4f ��t�' 1��R I Address - '�`r I rW W�C' " Phone zo_ `F <br /> I <br /> 01 <br /> Contractor S4_1 f Address License No. Phone <br /> TYPE OF WELLIPUMP: 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 /> I . <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom C] Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ! ❑ Domestic/Private O Gravel Pack: ❑ Tracy Type of Casing Specifications <br /> I—I Public -1 Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __.Approx. Depth,. I Ix Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'I <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION K REPAIR/ADDITION l I DESTRUCTION 7 INo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence x Commercial Other <br /> Number of living units: 1 Number of bedrooms . . f <br /> ! Character of soil to a depth of 3 feet: f Water table depth <br /> SEPTIC TANK Type/Mfg Capacity J;L00 12CI. No. Compartments <br /> PKG. TREATMENT PL C f Method of Disposal <br /> ! Distance to nearest: Well i ll Foundation s_— -.. Property Line ).(? I <br /> i I <br /> 4 <br /> LEACHING LINE ` No. & Length of lines rL Total length/size <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation Property Line <br /> l I f.. <br /> SEEPAGE PITS l I Depth ! Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 , <br /> 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 /> 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 call for all required inspections. Complete drawing on reverse side. ` r, <br /> Signed X Title: rt l!` Date: �� L 3 19" <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date-2, Area <br /> Pit or Grout Inspection by ,,ate Final Inspection by Date <br /> wu - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -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 /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIYNO. <br /> INFO <br /> +.EH 13-241RM1/851 7 0 <br /> EH 14-ZO <br />