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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 /> t r (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health &trict for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaqujin�County Ordinance No.549 for sewage or No. 1862 forLwell/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District' <br /> Job Address ;�els: �:Sb t ao,!V— <br /> city ��_ Lot Size <br /> PM¢. <br /> Owne'r's Nam Address ,SA me- Phone <br /> ��"i�_Address �� T/F/I/-License No. <br /> Contractor-?A LIS6 s . phone• r <br /> – <br /> TYPE OF WELL/PUMP:-,? ., <br /> NEW WELL f❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMPNSTALLATION,fD, SYSTEM REPAIR ❑ OTHER p <br /> DISTANCE TO NEAREST: SEPTIC TANK ' ��- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT.UEiE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca t I Dia:of Well Excavation_ <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Cl Tracy 1. r Type of Casin <br /> ❑ Public '�' ' ..� g Specifications <br /> ❑ Other - -^❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approx.'Depth,,";.❑ Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump Hip t State Work Done <br /> Well Destruction ❑ Well Diameter ' ' " Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION A DESTRUCTION 41 (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> Installation will serve: Residence Commercial sOthe r t <br /> Number of living units: _>— Number of bedrooms_.2 , <br /> Character of soil to a depth of 3 feet: i g <br /> Water table depth <br /> SEPTIC TANK © Type/Mfg `I_'0WJ7A1UUl1`_ Capacity. 1 00 No. Compartments <br /> PKG. TREATMENT PLT. 1-11 � Method of Disposal <br /> Distance to nearest: Well ? Foundation Property Line <br /> I <br /> LEACHING LINE 10 No. & Length of lines ! Total length/size <br /> FILTER BED ❑ Distance to nearest: Well w } F.oundetion Property Line <br /> t' e y <br /> SEEPAGE PITS <br /> ■ Depth ;2.y . Size_-?—?o .. t Number <br /> SUMPS ❑ Distance to nearest: Well � <br /> Faunclation_;3D Property Line O <br /> DISPOSAL PONDS ❑ I � ;Y:. <br /> hereby certify that I have prepared this application and that the work will"be,46ne 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 become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature t <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." 'Y={ <br /> The appl' t must call f r all required inspections. Complete drawing on re rse side. y <br /> Signed Title: Date: 0 JJ—R1 <br /> FOR DEPARTMENT USE ONLY -2 <br /> Application Accepted by Date A Area J <br /> Pi o Grout Inspect' by ate Final Inspection by 07((}}0'`t" �,mac,,,mate <br /> d-t..rra.� .QWcr", ! l <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ 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 /> FEE ,.AMOUNT DUE—n-- .—AMOUNT-REMITTED - CK__ <br /> INFO CASH '.""'RECEIVED BY DATE —PERMIT'NO:- <br /> + EH 13-24(RM 1/05) <br /> EH 14-28 <br />