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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r. <br /> �C City � 't i Lot Size PM <br /> Job Address <br /> Address Phone 7Q3 <br /> Owner's Name -Q ! <br /> ( P71tr���Ql' (�! Phon7 <br /> e VP Z <br /> Contractor's Name �, f�7tr License No. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 17 <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ll <br /> INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION SPECIFICATIO <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. of Well Excavatl p <br /> Type of Casing PI/ C—• Specificatlons 40r r <br /> Domestic/Private Gravel Pack El Tracy Type of Grout '® <br /> ❑ Public Ll Other ❑ Delta Depth of Grout Seal —z — yp .,, <br /> ❑ Irrigation --Approx. Depth ❑ Eastern 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 -- ~"""' <br /> Filler Material (Below 501 f, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION a REPAIR/ADDITION ❑ DESTRUCTION ❑ iNostiwsh n m permittedmiitt <br /> availableed if public sewer is <br /> Installation will serve: Residence— Commercial_ Other = - <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ( Water table depth fi i <br /> SEPTIC TANK L] Type/Mfg Capacity No. Compartments <br /> !!R <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ ; - <br /> 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 F1Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 /> k. <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 shalt not <br /> I 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 /> i The applicant m I for all re ui d inspections. Complete drawing on re rse side. <br /> ! — Date: <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY ' <br /> Date Area <br /> Application Accepted by �^ <br /> t Piior�Grqut Inspection by Date <br /> �Z?� �Final Inspection by Date ./ <br /> ��AdditionnaallComments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6365 <br /> Applicant- Return all s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> copies to: Environmental Health-Permit/Service <br /> CK RECEIVED$Y DATE PERMIT NO. <br /> ( IFEE NFOZAMOUNT DUE 9 AMOUNT REMITTED CASH <br /> +EH 13.24(REV.10153)EH 1426 ` <br />