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APPLICATION FOR PERMIT s <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I` 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 wewpump and the Rules and Regulations of the San Joaquin <br /> I Local Health District. +1 <br /> City O Lot Size PM. <br /> Job AddressO <br /> vvV <br /> ` Address Phone <br /> Owner's Name� � <br /> Address (cense Na,El <br /> Phone t <br /> Contractor f <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ ��ESTRU ION ❑ " <br /> 4 PUMP INSTALLATION ❑ SYSTEM REPAIR,�� OTHER ❑ <br /> ` DISPOSAL FLD. PROP. LINE <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> t } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i .. <br /> INTEND USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom O Manteca;' Dia.,of Well Excavation.'- , Dia. of Well Casing <br /> ❑ �nt: l , <br /> i c/Private ❑ Gravel Pack ❑ Tracy,,%. Type,f.Casingr. - Specifications <br /> ' � Cl"Oihef' T"""•.:_�'❑-D61f�"'"' �"" "DepTh75f"Grout-Seal""", <br /> Type of'Grout4`°_ - <br /> I'1 Public 0— <br /> I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Hone ❑ Type of Pump <br /> H P f State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'} <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> *fa available within 20o feet.) y <br /> i r <br /> Installation will serve: Residence Commercial Other ' <br /> `" } ' <br /> Number of living units: Number of bedrooms ;, ,�,.,- —TT-..-.--•J O <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT" ❑ y {_Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> f LEACHING LINE' Cl No- & Length of lines Total length/size <br /> FILTER BED f � ❑ Distance to nearest: Well Fbundation-jn -� Property-L•ine <br /> SEEPAGE PITS , I I Depth'I Size _ Number <br /> SUMPS �^ ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSA Si ❑ <br /> his application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby c rtify hat-( have prepared t <br /> rules and egula ons of the San aquin LOW Health Di§trict. <br /> Home ow or or censed agent's gnature Mies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ an per n in such man as to b o e subj t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> F certifies the ing: "I certify tin rf rman f the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of C i ornia." <br /> I 00* <br /> The applic n c al r i i i s. plate drawing on s� / <br /> Signed X � <br /> Title: Date: �+ <br /> FOR DEpARTMENT USE ONLY <br /> V <br /> Application A�cepted by Data Area / <br /> \�� Addill,i <br /> Grout Inspection by <br /> Date Final Inspection by <br /> Dat <br /> onal Comments: <br /> 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 <br /> ant - Returnall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i=AMOUNTAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> CASH <br /> EH13-241RfV.rinsl (/"V�. [ '� <br /> EH 14-26 <br />