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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE 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. <br />Job Addressh ` <br />t � city 5C Lot Size��j''' =s PM <br />Owner's Name u L G f Address ��v''L Phone V2, 3, S - <br />Contractor Address License No. Phone <br />I Trt Vr YYtLL11'UMt': <br />DISTANCE TO NEAREST: <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />I -i Public <br />I I Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR C7 OTHER ❑ r <br />SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL <br />❑ Open Bottom <br />❑ Gravel Pack <br />❑ Other <br />--Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Manteca Dia. of Well Excavation <br />❑ Tracy Type of Casing <br />❑ Delta Depth of Grout Seal <br />I I Eastern Surface Seal Installed by <br />H. P. . State Work Done _ <br />— Sealing Material Itop 50') <br />Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br />Installation will serve: Residence Commercial — Other available within 200 feet.) <br />Number of living units: ---L-_- Number of bedroomsC <br />Character of soil to a depth of 3 feet: O Water table depth / <br />SEPTIC TANK W- Type/Mfg L CO 'C Capacity z O 0 No. Compartments <br />PKG. TREATMENT PLT. ❑ r Method of Disposal <br />Distance to nearest: Well_ Foundation Property Line <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />NO <br />LEACHING LINE V --`No. & Length of lines ' 160 Total length /size <br />FILTER BED ❑ Distance to nearest: Well <br />Foundation _���_ Property Line , <br />SEEPAGE PITS I ) Depth Size Number <br />SUMPS ❑ Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS CI <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, enc <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 follow' "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 Cali rni ' <br />The applicant call If It re d in ompl drawing on r ide. /r) <br />Signed X i /"J <br />Title. 11 *ate: <br />F. DEPARTMENT USE ONLY /j <br />Application Accepted by Date 'r " ' gree /7 <br />Pit or Grout Inspection by Date _ Final Inspection by Date <br />Additional Comments: <br />❑ 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 D K <br />INFO UE AMiUNT REMITTED CASH RECEIVED BY GATE PERMIT'NO. <br />•.EH13241HEV,iixsY � �� � �� __L�`g � <br />EH 14-26 1 <br />1 / <br />