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T <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 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 District. <br /> ori? .�� L i. S ' <br /> Job Address � dCwJ[_' lQ�b/Sed City 7L �/�� � n'Lot�.S'iz/e���x��/�' PM <br /> ,�/� / 1002�� C]/�r[�/'N/y- �/��{r�L Phone <br /> Owner's Name �� �,1 Z �'+ Address <br /> Contractor /c� Address L 't License No_a U5 2,� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ W LL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ('1 Public n Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation __ Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done----f3-,. Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION (&K'DESTRUCTION I_E I (No eptic system permitted if public sewer is J 'z� J►" <br /> t�C� 'r available within 200 feet.) <br /> ll <br /> Installation will serve: Residence_ Commercial� Other ��� <br /> J <br /> Number of living units: Number CCof bedroo s <br /> Character of soil to a depth of 3 feet: q IL Water table depth S <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE (]- No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to neaest t: Well Foundation f Property Line­20 f <br /> ZM <br /> E PITS Depth Size _ Number <br /> P i �4 Distance to nearest: Wel Foundation_6_0_1_*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 /> 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 equired inspections. Complete drawing on reverse side. p <br /> Signed Xw(/`f�P Title: !6W uek Date: <br /> FOR DEPARTMENT USE ONLY <br /> �cipted by Date � Areon by Date, �-a Final Inspection by <br /> w <br /> 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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. <br /> . EH13-24(REV.I/Hro ��) / �Y2 <br /> EH 1426 LA O (OBJ <br />