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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT u <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 /> 1 <br /> y made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weli/pump and the Rules and Regulations of the San Joaquin <br /> p _ Local Health District. <br /> City Lot Size PM <br /> ~,,/t Jab Address.- <br /> I ;I/ Phone <br /> Owner's Name .y�I �� - Address ' <br /> Address. Q �- �O if�License No.- <br /> �� ''�� �� �� ..��.. Phone_ <br /> Contractor��! h�I-�— <br /> T TYPE OF WELL/PUMP: NEW WELL M WELL REPLACEMENT © DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> w DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE �,,_ TY:PE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Sp <br /> ❑ Domestic/Private 17Gra;el Pack LJ Tracy Type of Casing` eifications <br /> c <br /> Fl Public Cl OEher [7Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done C. Type of Pump H.P. State Work Done <br /> Sealing Material 5011 % <br /> Well Destruction De_N <br /> Diameter 9 p <br /> Xepth ! Filler Material IBelow 541 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I PAIR/ADDITION I 1 DESTRUCTION E I INo septic system permitted if public sewer is <br /> :available within 200 feet.) <br /> Installation will serve: Re -dente`-commercial_ Otheir <br /> t <br /> Number of living units: - Number of bedrooms <br /> �' C �] p� Water labia depth <br /> Character of soil to a depth of.3 feet: �.��-,Qc ' r /� MI._ <br /> # � t Capacity Z6 No. Compartments <br /> SEPTIC TANK Q,�Ypelyfg, -C In <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to neatest: WellFoundatfoni _-� Property Line -� <br /> t ti <br /> LEACHING LINE_ &-�. & Length of lines <br /> '! ZQU. t Total length/size <br /> FILTER BED El Distance'to nearest: Wgll Foundation _- Property Line <br /> 4 �- ^ <br /> *"—SEEPAGE PITS N <br /> i �DePth Number <br /> SUMPS Cl 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 /> i rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agents 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`subjVffto Workman's corripensatibri laws of California." Contractor's hiring or sub-contracting signature <br /> cert the following: "I rtify 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 California.' <br /> The applicant call for all.r aired r spa io S. C e •dr Ing on r verse sid :, <br /> Signe itie: Date: <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> Application Accepted by Date Area <br /> 7,6 <br /> Pit or Grout Inspection by Date Final Inspection by Date 7, T <br /> I 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 /> I I � <br /> nAMOUNT DUE AMOUNT REMITTED CASH RECEIVED ISY DATEPERMITNO. <br /> / ��{^ <br /> +'EH 13.241REV.5/85] t� / `� <br /> a EH 14-2a <br />