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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 /> (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. .r <br /> Job Address /ZN_4c" 7y, City W Lot Size PM: ; <br /> Owner's Name Address /70 I 4) "5a. Phone <br /> ' 1 <br /> Contract i� r Yz& Address_1,00, 76 7 ze-01C-L License NoWR�76_ Phone SIU <br /> TYPE OF WELL/PUMP: 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 V <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'r' Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed;'by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth r Material (Below ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ !PAI ADDITION DESTRUCTION ❑ (No septic system permittedifpublic sewer is <br /> I <br /> available within 200 feet.)-'- <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: --I— Number of edrooms r <br /> f <br /> Character of soil to a depth of 3 feet: `1 ( Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-,L-1 No. Compartments`' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal' <br /> Distance to nearest:—Well---. Foundation l Property Line . ; L <br /> i <br /> -w, LEACHING LINE V­No. & Length of lines 7 –�Total-length[size--- -x <br /> FILTER BED ❑ Distance to nearest: Well Foundation / <br /> l�^� �� Property Line 1� <br /> �v �. 5-M <br /> SEEPAGE PITS ❑ Depth Size' x, 0 1 !Number <br /> SUMPS Z!Distance to nearest' Well�[�`r Foundation f Property Line 57_ <br /> DISPOSAL PONDS ❑ <i ,4 } _ <br /> 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 /> r rules and regulations of the San Joaquin Local Health District. ! q s i' <br /> Home owner or licensed agent's signature certifies.the following: "I certify that-Wfhe performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to became 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 mustfl for all requ' din actions. Complete drawing on reverse side. <br /> Signed X Title: V :� Date: <br /> FOR DEPARTMENT USE ONLY <br /> ' Application Accepted by 1 Date r✓ Area <br /> Pit or Grout Inspection by f -Fina! Inspection by Date w Date <br /> Additional Comments: `Y _ <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 n Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.!Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT�NO. <br /> a EH 13-241REV.t/Bsy U �Z—e <br /> EH 1429 <br /> l , <br />