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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Lit - <br /> �C2 <br /> Telephone Q091 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 N1862 <br /> Rfcy( elllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 1h0WA6 City Lot Size PM <br /> Job Address <br /> (` Q <br /> l Address �L Phones <br /> Owner's Name _ <br /> It 4-1 <br /> I C ntractor Address � � Lol l�nse It �7 qV�r�sPhone <br /> 0 <br /> TYPE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLAT N ❑ SYSTE EPAIR 111 ��OTHER15"_"(`/' <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO., PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> p Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications IVA <br /> l"1 Public Other ,�4 Delta Depth of Grout Seal Type of Grout —. <br /> k I 1 Jrrigarion 3�?Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done E7 Type of Pump H.P. Statip Work D ne T <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 ' <br /> Depth Filer Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION I i REPAIR/ADDITION l l DESTRUCTION I I aNailabpticle tin system rented if public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of riving units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments [� <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> C Distance to nearest: Well Foundation 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 l I Depth Size Number <br /> ' SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 11 <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 /> Horne 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."Contractors 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 applica must ll for all requ a inspections. Complete drawing,an reverse side <br /> C:­11 <br /> Title:S " Lam44xate: <br /> �� l✓ % 0 <br /> FOR DEPARTMENT USE ONLY <br /> Applicatign Acc pie by <br /> Date M QD Area e <br /> —,6mg <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 465-5781 ❑ Lodi 369-3621 13Manteca 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 DUE AMOUNT REMITt <br /> CASH RECEIVED BY DATE ?ERMIT Nq. <br /> INFO <br /> CH 13-24 MEV.I e"bi 60� 101? v o�77� <br /> FH 14.26 <br />