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APPLICATION FOR PERMIT <br /> SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR-FROM DATE ISSUED <br /> r' <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 applicati\ismade in compliance with San Joaquin CounLocal Health District. tYOrdinance No.549 for sewage or No. 1662 for well/pump and the Aures and Regulations of the San Joa <br /> a <br /> Job Address /0 + <br /> t City—1309 Lot Size PM <br /> ,Owner's Name <br /> Phone /z~ <br /> Contractor <br /> Addres z <br /> TYPE OF WELL/PUMP: .. NEW WELL ❑ License No.f / Phon <br /> WELL AEPLACENIEN I <br /> PUMP INSTALLATION E2 DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK '" SYSTEM REPAIR 0 OTHER EISEWER LINES DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial.. ❑ Open Bottom —��' <br /> 1-3 Domesticl Private ❑ Manteca Dia. of Well Excavation <br /> ❑ Gravel Pack- ," ❑ Tracy T Dia: of Well Casing <br /> M Public Cl Other ype of Casing <br /> [� Delta Depth of Grout Seal Specifications <br /> I i Irrigation l —_Approx. Depth I I!Eastern _ Type of Grout <br /> Repair Work Done Surface Seal Installed by ' " <br /> ❑ Type of Pump t H.P. <br /> Well Destruction 0 Well Diameter State Work Done <br /> Sealing Material ftop;50') <br /> Depth T m <br /> TYPE OF Filler Material (Below 50') <br /> SEPTIC WORK: NEW INSTALLATION 1.7 REPAIR/ADDITION m 1 <br /> DESTRUCTION I 1 (fJo septic system permitted iF public sewer is <br /> Installation will serve: ResidenceCCommercialh available within 200 feet.I <br /> �. . <br /> Number of living units: Other <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: m <br /> SEPTIC TANK ❑ Type/Mfg CapacityWater table depth <br /> w ���_ <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> Distance to nearest: W' -- "t Method of Disposal <br /> ell Foundation h r r <br /> Property Line <br /> LEACHING LINE XC No. & Length of lines z <br /> FILTER BED - ❑ Distance to riearest: Well C 2Z- Total length/size r/ <br /> Foundation r i k <br /> Property Line <br /> SEEPAGE PITS ! I Depthr <br /> SUMPS Size Number <br /> D Distance to nearest: Well I <br /> DISPOSAL PONDS ❑ Foundation ' Property Line 1 <br /> hereby certify that i have <br /> prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and d <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 <br /> employ any person in such manner as to become subject to workman's compensation lawsofCalifonce rnia•"Contractor's work for lh rings or sub'cont acing s gnaltu�e <br /> certifies the following: "I certify that in the Performance of the work for which this Permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> The applicant must.call for all required in ions. Complete''drawing on reverse side. <br /> . Signed <br /> le: , I <br /> Date. p— <br /> FOR MENT USE ONLY <br /> Application Accepted by <br /> - Date Area <br /> Pit or Grout inspection by ! " <br /> Date Final Inspection by <br /> w Additional Comments:. f Date <br /> 0 Stk " 466-6781 0 Lodi 369-3621 ❑ Manteca 823-7104Tracy / <br /> - } 5- 5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazelton A3 e.,P.O. Box 2009; Stk., CA 95201 <br /> •� i <br /> FEE MOUNT DUE CK <br /> INF AMOUNT'REMITTED RECEIVED 8Y <br /> I�`� {� SH ` ! DATE HRMO. <br /> t EH 13-24{AEV.i i N 51 Q {)�-.. i �/ ' o��� Y S <br /> EH 11-2t{ _ `J <br /> S_y �1 D y� <br />