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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT VAX-) r <br /> 1601 E. HAZELTON AVESTOCKTON, CA <br /> f Telephone (209) 466-6781 .. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate] <br /> i <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. .." tg, <br /> "If <br /> r r City Lot Size <br /> PM <br /> Job Address <br /> Phone <br /> Owner's Name <br /> r Address <br /> Address License No. Phone <br /> i Contractor M <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION 171 `\ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I DISTANCE TO NEARE TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> l <br /> Cl Industrial ❑ Open Bottom El Manteca w a Dia. of Well on <br /> Dia. of Well Casing <br /> t � , Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑"Tracy s yp g <br /> EJ Public EJ Other Ll Delta t Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern t f Surface Seal Installed by ✓ <br /> kState Work Done <br /> Repair Work Done "❑ Type of Pump <br /> H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW IN ❑ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence-A<' Commercial_ Others R ; <br /> Number of living units: -- Number of b drooms f. �- `- �•�, <br /> I Character of soil to a dept of 3 feet: F <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg — CapacityNo. Compartments <br /> i PKG. TREATMENT PLT. Ll -41 <br /> Method of Disposal <br /> Distance to'nearest:' Well ^'"" "F66ndation Property Line <br /> I LEACHING LINE El No. length/size No. & Length of lines ..- f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> 9 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS i. ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ o y <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cciunty ordinances, state laws, and <br /> rules and regulations of the San Joaquin.Locai Health District. r <br /> Home owner or licensed agent's signature certifies the following: "I certrfy that in the performance of the_ rawork 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-Califomia." Contctor`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 tsubject to workman's compensa- <br /> tion laws of California." <br /> k inspections."Complete drawing on_reverse-side. <br /> The applicant m all for all re it <br /> 3' <br /> _i Signed Title: Date: <br /> 7� 1'= <br /> I FOR EPARTMEN USE ONLY 1 <br /> f <br /> Application Accepted by Date Area <br /> T Date Finallnspectionby Date ! J <br /> Pit or Grout Inspection.by <br /> Additional Comments: O a k�- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 t ❑ Tracy 8354085. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i. <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. <br /> INFO �G/ <br /> + EH 13-24(REV.1/a5) �,St CSO ) r ���� <br /> EH W28 <br />