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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r i <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ., ,AComplete in Triplicate)r'.l:..!i? ttw e <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 Regulatio s of the San Joaquin <br /> Local Health District. F do 6d <br /> Job Address _ t2 <br /> _ City Lot Size PM <br /> -" Owner's Name Address -.f» D► O / V�' '"` Phone 2 �/ V 7 i � <br /> Contractor AC ✓ rImT _ lk � �L <br /> License . one ! <br /> C TYPE OF WELL/PUMP: NEW WELY ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> R r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE ; <br /> I t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS__ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cr <br /> f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other U Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth; ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done w <br /> .t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below.501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ tNo septic system permitted if public sewer is G <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: ' Number of bedrooms �a <br /> ' Character of soil to a depth of 3 feet: ' <br /> p Water table depth <br /> SEPTIC TANK ❑ Type/Mfg capacity_.aOID No. Compartments I <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of linesIr To I length/size <br /> FILTER BED ❑ Distanc to Warest: Well Foundation Property Line#2 <br /> (1 r <br /> r\4 <br /> SEEPAGE PITS` Depth Sizer`I!, � Number 4 <br /> SUMPS !r EJ Distance to neare v- Well� Foundation yG Property Line <br /> DISPOSAL PONDS ❑ t <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 /> 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 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." 4 1 <br /> :'The applic must call fol all mired"inspections. Complete drawing on'reverse side. t <br /> Signed X µ Title:' Date: <br /> FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date S—\Z--a Area <br /> r it or rout Inspection by { <br /> 9 �.,, L Da�j �_,nal Inspection by _ Date <br /> diti nal Comments: t <br /> r❑ Stkr 466-6781 ❑ Lodi 369.3621 ❑ Manteca 82377104 ❑ Tracy 835-6385 <br /> iApplicant- Return all copies to: Environmental Health�Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,.CA 95201 <br /> „ <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED XK RECEIVED BY' DATE PERMI7'NO. <br /> r _ <br /> + EH13-241REV.-I m51 <br /> EH 14-26Z-, ^ <br />