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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> :7 =1601 E. HAZEL i ON AVE.;STOCKTON, CA <br /> * Telephone (209) 466-6781 <br /> .4(..`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 vAh 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 _ ZJ:_14 �. 1,4 f//�i CityS ollKer& Lot Size M Y /J 47 PM <br /> Owner's Name "/TC/Y Address. Phone <br /> 1 <br /> Contractor's Name --V13'1,14' License No!N Phone 65-' 4t 7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. _PROP. LINE <br /> FOUNDATION AglRICULTURE;WELL " OTHER WELL t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑ Open BottomElManteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private 11 Gravel Pack"R_ "�-❑ Tracy Type of Casing Specifications " <br /> ❑"Public ❑ Other 0 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑'Eastern M Surface Seal.lnstalled by <br /> Repair Work Done ❑ Type of Pump H.0. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> k Depth Filler Material {Below 501 l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 4 Commercial_, Other <br /> Number of living units:._ Number of bedrooms ' <br /> Character of soil to a depthof`3 feet Y "` '" Water table depth <br /> SEPTIC TANK &""Type/Mfg "ACRA&Z _ Capacity_ /Z 0,6) ^Nod Compartments <br /> PKG, TREATMENT PLT. ❑ _. o "4f 'Method of Disposal ! 7-r <br /> Distance to nearest: Well. Foundation r Property Line–i._ <br /> LEACHING LINE & Length of lines _2 Total length/size Z a <br /> FILTER BED ElDistance to nearest: Well Foundation�/E7 ` Property Line . <br /> SEEPAGE�PITS Depth -2 Size 7 3 Number <br /> iSUMPS ❑ Distance to nearest:` Well Foundation r Property Line •; -"— <br /> DISPOSAL PONDS ❑ Gti1 i ' <br /> I hereby certify that I have prepared this application and that the work will be'done in`accordan with San Joaquin county ordinancers, 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."Contractoes hiring or sub-contracting signature <br /> E 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 call for all required inspections. Complete drawing on reverse side. <br /> i <br /> Signed X Title: Date: < //O <br /> FOR DEPARTMENT USE ONLY <br /> Acolication Accepted by Date reek R <br /> Pit r Grout Inspection by _ �.M Bete Finai Inspection by x Date <br /> Additional Comments: – - -–s <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 /> CK 0 <br /> FEE INFO a AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PE�R(MIT NO. <br /> + EH 13-24(REV. 10183) �'Iq- 5--O_14 - `"p —� -g q-.3 6 <br /> EH 14-28 f l <br />