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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.p <br /> Job Address �w�� -�r / <br /> City Lot Size /.4, PM <br /> Owner's Name LQ� SMr D'L.� Address a �IdA"o ._/[�v / Phone a— p <br /> Contractor 4 Address_License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTE EPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE c �� <br /> FOUNDATION AGR ULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy T e of CasingDia. of Well Casing <br /> Specifications <br /> FI Public ❑ Other El Delta Dept of Grout Seal <br /> Type of Grout <br /> I I Irrigation _ <br /> g ­Approx. Depth I I Easte 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 Filler Material (Below 501 <br /> YPE OF SEPTIC WORK: NEW INSTALLATION REIyAIR/ADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> Installation will serve: Residence A, Commercial_ Other available within 200 feet.) <br /> Number of living units: Number of bed r ms <br /> Character of soil to a depth of 3 feet: 07 b(� <br /> `` Water table depth <br /> SEPTIC TANK <br /> lY✓Type/Mfg ��� �D✓LC t G Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. [I / Method of Di�posal <br /> Distance to nearest: Well_ _ Foundation 1— Property Line _ <br /> LF <br /> ACHING LINE P�No. & Length of lines T tar length/size <br /> LTER BED ❑ Distance to nearest: Well �s O Foundation <br /> Property Line <br /> EPAGE PITS I I Depth Size <br /> MPS Number <br /> Cl Distance to nearest: Well Foundation Property Line <br /> SPOSAL PONDS ❑ <br /> ereby 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. r <br /> Home owner or licensed agent's signature certifies the following: "1 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 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 /> T e applicant must c for all requir in pections. Complete drawing on reverse side. <br /> 01 <br /> Signed X <br /> Date: <br /> a F DEPARTMENT USE ONLY <br /> Application Accepted byY � � Date ! 9 <br /> 9 Area <br /> Pit or Grout Inspection by D as Final Inspection by .;F / - � <br /> t Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 x. <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 <br /> INFO 7 <br /> —,_ CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24(REV.fixe) <br /> EH 14-26 <br />