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r <br /> Ae <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH'DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466 6781 <br /> N 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. / <br /> 1 <br /> City <br /> Job Address Lot SizeJOSI(LIgS PM <br /> i r1 �j-7 <br /> Owner's Name ��� `' Address .I(pCX ` �-" Phone <br /> Address.' �C1 �a License No:3�ZZ(" Phone <br /> >Contrado <br /> TYPE OF WELL/PUMP: = NEW-WELL..] aux " --WELL REPLACEMENT Q DESTRUCTION ❑ <br /> i rPUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `�^ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.. - -- <br />` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E1 Industrial ❑ Open Bottom ED Manteca ' Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type%of Casing Specifications <br /> f"1 Public [1 Other C1 Defta Deptt'oaf Grout Seal Type of Grout f - <br /> I I irrigation --Approx. Depth I I 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 Filler Material(Below'50') <br /> TYPE OF SEPTIC WORK: NEW IN I. REPAIR/ADDITION I I 'DESTRUCTION { I (No-septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence y Commercial r� 4Other <br /> Number of living units: Number f Vadroqml I <br /> ` Character of sotl to a depth of 3 feet: , Water table depth- <br /> SEPTIC TANK U?" �Type/Mfg Capacity_.AJj2_Q No. Compartments <br /> PKG. TREATMENT PLT. ❑ f ► r .�. .t `-Method of Disposal <br /> T oL <br /> I Distance to nearest:"Y" 1Neli"�Q `�'Foundation_.� Property Line s21 <br /> LEACHING LINE LAS No. & Length of lines y 0 Total length/size 04 <br /> FILTER BED ❑ Distance to nearest: {Well 106' Foundation fid -_— Property Line 50 <br /> SEEPAGE PITS IH Dep 5 �-'" -Site Number <br /> ' <br /> F 'SUMPS L] Distance-tonear est: Well 9 SO- Foundation © Property Line <br /> _`­.. DISPOSAL PONDS ---Cj+,.:: �'+.e --- �., _ � _ 4.•, - " -= <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 /> l 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, 1 shall not <br /> employ any person in such manner A 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 e work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." .., <br /> 3.The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPA1ffMFNT_09E ONLY <br /> Application Accepted by 1 r Date Areas -� <br /> P" .or Grout inspectiort by Date Final Inspection byDate � 7 <br /> la <br /> Additional Comments: <br /> ❑ Stk 466'6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA8H RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> • + EH 13-24 1REV.I/9 51 <br /> EH 14-26 6� <br />