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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 /> unty Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Co <br /> Local Health District. <br /> w, _ <br /> City <br /> LNat'Size PM <br /> Job Address <br /> Owner's Name X/G' Address 7 �T 5 SGL Phone <br /> X39'- to 3`l <br /> Af_X <br /> Contractor <br /> Address c-4r l - License No.�Phone ' �^ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i DESTRUCTION 13 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D l OTHER D <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE € <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation b <br /> Type of Casing I Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack 13 Tracy YP g 1 1 Type of Grout <br /> ❑ Other E3 Delta Delta Depth of Grout Seal <br /> C1 Public ; <br /> ❑ Irrigation. ---Approx. Depth ❑ Eastern Surface Seal Installed by _ , <br /> ` Repair Work Done E Type of Pump H.P. i Sta Work Done {may <br /> Well Destruction J Well Diameter Sealing Material Itop 501 1 _' <br /> i r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> F t available within 200 feet.) t <br /> eve Commercial Other <br /> Installation will serve: Residence yam•'` <br /> k Number of living units:� Number of bedrooms` .� ✓ <br /> , / JI;�, Water table depth t <br /> Charecter�of soil to a depth of 3•feet: { <br /> SEPTIC TANK ❑ Type/Mfg lv ' !_ Capacity No. Compartments <br /> �. '> <br /> PKG. TREATMENT PLT. ❑ Metlfrod of Disposalx4=' ` <br /> Distance to nearest: Well <br /> 'Foundation r •`Pr&pCrtylLine <br /> K r <br /> ` - - 4 /..�-� � -'fix• .� { <br /> LEACHING LINE IJNo. & Length of lines f Total length/size <br /> FILTER SED ElDistance to nearest: Wel�,� Foundati06 - Property Line <br /> SEEPAGE PITS LlDepth l Size Number <br /> SUMPS D Distance to nearest: Well Foundation � ;Property Line <br /> Via. +ti•.t— � <br /> 1 DISPOSAL PONDS ❑ <br /> this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the-following: "I-cerfify-that-in-the-performanceof-tlfe-work for w`FiichF'4his permit is issued, I shall not <br /> 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 person's bject to workman's compensa- <br /> tion laws of)California." <br /> The applicant must call for all equir d inspections. Complete drawing on reverse side. <br /> t Date: <br /> Signed i Title: <br /> `FOR DEPARTMENT USE ONLY � 1l <br /> Application Accepted by Date�; r "- " Area O� <br /> S <br /> t Pit or Grout'Inspection by <br /> Date Final Inspection by ` Date <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 Manteca 823-7104 <br /> Ej ManEl Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E Hazehon Ave. ,P O Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> + EH 13-241REV.I/B$) <br /> EH 14-26 <br />