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R' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i 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 /> 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 Distdct. <br /> Job Address �1_ VINe5 57— City <br /> .577<Al Lot Size PM 1 <br /> Owner's Name /Q�e Y-15 9 7" - Address S411-1e— Phone 4_62_4d5P91 <br /> Contractor_ FLdYD E, Address Z Al, License No. 4ZZ-- X7& Phone ,V-3'77 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ^- DESTRUCTION ❑ <br /> PUMP INSTALLATION-E- �- --•SYSTEM-REPAIR-E1---M——"OTHER ❑ " <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t PROP. LINE <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ti PITS/SUMPS C� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA "_CONSTRUCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial i ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of W611 Cising <br /> ❑ Domestic/Private ❑ Gravel Pack _ ❑ Tracy Type of Casing Specifications t <br /> (l Public Ll Other 1­7Delta Depth of Grout Seal Type of Grout _. <br /> t 1-1 Irrigation ' --Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ,L1 Type of Pump H.P. State Work Done <br /> Well Destruction ❑_ Well Diameter Sealing Material (top 501 ` <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION l ESTRUCTION I (No sept system permitted if public sewer is <br /> availabl within 200 feet-) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: Number of bedrooms / { <br /> Character of soil to a depth of 3 feet: % ' Water table depth � <br /> SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. ❑ r. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t � , <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well —Foundation Property Line <br /> SEEPAGE PITS i I Depth _Size � Number I <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line f ale <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 /> rules and regulations of the San Joaquin Local Health Di%trict. <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 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. II <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ✓ 4 ze, Date r ~� Area <br /> Vu <br /> Pit or Grout Inspection by (` D to Final Inspection by Date <br /> Additional Comments: �J / <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 2008, Stk., CA 95201 <br /> y <br /> FEE' AMOUNT DUE AMOUNT REMITTED CK RECOVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> +"EH t3-241AEV.F/851 <br /> EH 1 -26 <br /> _a <br />