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APPLICATION FOR PERMIT l <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 + <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED { <br /> (Complete in Triplicate) . . .,•r�� > E f -A <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 4 <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 w <br /> Local Health District. r F <br /> Job Address City Lot Size _ �- PM -- <br /> Owner's Name �•!/0�' Address .2!C <br /> � - A.s��� u Phone _ <br /> Contractor's Name �+'- License No. 30,57.2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ m WELL REPLACEMENT ❑ OESTRUCTlON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation_ Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout— <br /> El <br /> rout❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed bye' <br /> Repair Work Done ❑ Type of Pump H.P. _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 U' <br /> . Depth Filler Material (Belz 501 <br /> C;TYPDOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other F <br /> Number of living units: —J — Number of bedrooms ` <br /> F � <br /> Character of soil to a depth of 3 feet: C PC 124 --Water table depth <br /> SEPTIC TANK �` ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT 17 k Method of Disposal <br /> 4 Distance to nearest: Well Foundation Property Line <br /> J , r <br /> LEACHING LINE k L9­—N0. & Length of lines = 1�� � L�_ T�otal length/size <br /> FILTER BED -' _❑ Distance to nearest: ell 7$19& - Foundation� Property Line _ <br /> SEEPAGE PITS ., Depth Size O Ly Number 4 <br /> SUMPS �'4 ❑ Distance to nearest: Well_�^ Foundation 0 'l Property Line ..._— <br /> DISPOSAL PONDS ❑ <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." k <br /> The applicant must call r all required inspections. Complete drawing on reVerse side. .. <br /> Signed Title: ° � Y w Date: o—I <br /> s <br /> I FOR DEPARTMENT USE ONLY <br /> Application Accepted by ! 1 Date . Area G <br /> it r Grout Inspection by '� Date �- `� 'Final Inspection by Date <br /> Additional Comments: <br /> l ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED to CASIV H RECEIVED BY DATE` PERMIT"NO. <br /> INFO <br /> +EH 1324 iREV.10!831 <br /> EH 14-25 <br />