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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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 • City "V Lot Size PM <br /> Owner's Name -��� �z�►� �." Address ing 411 "I�++ti� W m Phone <br /> a <br /> U. 4� ] Z Gi k11 License No. " Phone <br /> Contractor �. � J+' Address -� N .2U oZ <br /> TYPE OF WELL/PUMP: NEW WELL ❑/ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 'Ll <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK ,"07)1. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> pis FOUNDATION AGRICULTURE WELL OTHER WELLZ.S`� PITS/SUMPS <br /> INTENDED USE--"- TYPE-OF WELL -PROBLEIVhAREA CONSTRUCTION SPECIFICATIONS a <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> _�*9omestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications <br /> ❑ Public ❑ Other L1 Delta Depth of Grout Seal Type of Grout <br /> El Irrigation r—._—Approx. Depth ❑ Eas 5-n Surface Seal Installed by <br /> � <br /> Repair Work Done Q Type of Pump a5-" -H.P. i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50.1 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑I DESTRUCTION Ll (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> p <br /> Installation will serveI: Residence_ Commerc'ial Other { e <br /> Number of living units: Number of bedrooms R b <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. ❑ 1 y Method,of Disposal . <br /> Distance to nearest: L 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 ❑ Depth Size Number ' <br /> f SUMPS ❑ Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS i ❑ S <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 /> 4 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 subiect,to.workman's compensation laws of California.':Contractor's hiring or sub-contracting signature <br /> certifies the following: "I'cer tify 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 applicant must call for II requireddspections. C plete drawing on reverse side. <br /> Signed Title: ``� - Date: r� ' k v <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate / Area +�!J <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 8355-6385 <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 REMITTED RECEIVED BY' DATE PERMIT NO. <br /> INFO <br /> + EH 13-241REV,1/-851- S. 1 d� &-c <br /> EH 14-26 - 1C� / ] <br />