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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> Job Address Ilk <br /> City Lot Size pM <br /> Owner's Name t - '20r r <br /> Address S rt i�—!+L .rrq hone <br /> Contractor's Name A 0, rC-cicense No. <br /> TYPE OF WELL/PUMP: NEW WEL _ Phone o.23' T <br /> WELL REPLACEMENT <br /> Li C1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q <br /> DISTANCE TO NEAREST; SEPTIC TANK OTHER C1SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationcr-N <br /> Well Casing ~ <br /> ❑ Domestic/Private El Gravel Pack ❑ Dia. of <br /> Tracy Type of Casing "z <br /> ❑ Public ❑ OtherSpecifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx. Depth El EasternType of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') N. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTiO (vailable within 200 feet.) <br /> Na septic system permitted if public sewer is <br /> ""�� <br /> 4 <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms fa <br /> Character of soil to a depth of 3 feet: C <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg d 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ y <br /> 1 9 Method of Disposal <br /> Distance to nearest: Well — Foundation Property Line V1 <br /> LEACHING LINE ❑ No. & Length of lines y <br /> FILTER BEDe <br /> ❑ Distance to nearest: Well Total length/siz <br /> Foundation Property Line <br /> SEEPAGE PiTS Q Depth Size i <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS LlProperty Line <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 /> 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 ome subject to workman's compensation <br /> certifies the following: ­f crtify that in a rformance of the work for whichierm'tVis issued,of shall employ Contractor's hiring or sub contracting signature <br /> tion laws of California." p p y persons subject to workman's compensa- <br /> The applicant or pectionB. Complete drawing on reverse side. <br /> Signed ' J� c <br /> _ Date: ` 42 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _l _ Date J/2 d <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date I <br /> Ad tikonal Comments: �+ 1 <br /> 466781 <br /> L1 Lodi 369-3621 ❑ Manteca 823-71 ❑��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 CK# <br /> INFO CASH RECEIVED BY DATE PERMIT`N0. <br />+ EH13-24 ff1EV.101931 / U y , O <br /> EH 14-28 <br />