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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. �y <br /> Job Address —Z9-J � 7Zii�.�r /CcG/� /��, City C�' Lot Size PM <br /> Owner's Name ert/0-9 t•++as hL Address f 34 <br /> Phone <br /> Contractor's Name J t a."'License No. 3 g Z-Z Phone <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 <br /> INTENDED USE TYPE OF WELL PROBLEMAREA 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 /> ❑ Irrigation __--Approx. Depth ❑ Eastern Surface Seal installed by s <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 50') <br /> Depth Filler Material {below 501 <br /> TYPE OF 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�Y _ CU <br /> Number of living units: 7) 1 Number of bedrooms Q� <br /> Character of soil to a depth of 3 feet: Is :ijl' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well j sposa��- <br /> Foundation Q Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I� Depth -2 Size <br /> Number 4 <br /> SUMPS ❑ Distance to nearest: Well I SO Foundation V 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 mannet.,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 pbrsons subject to workman's compensa- <br /> tion laws of California." 1 <br /> The applicant st call for all vire 'nspections. Complete drawing on reve7ide <br /> Signed Title: V r Date.14� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by f �� <br /> Date— g` Area <br /> 6)tr Grout Inspection by Date /' � r�++Finat Inspection by Date 3 <br /> Additional Comments: <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 171 Manteca 823-7104 ❑ Tracy 835-638.5 <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 CK RECEIVED BY DATE PERMIT`N0. <br /> INFO CASH <br /> + EH 13.24(REV.10/831 <br /> EH 1126 �S• �Q � 5-7 <br />