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APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T 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 Sari%Joaquin County Ordinance No.549 for sewage or No. 1862 for we and the Rules and Regulations of the San Joaquin + <br /> Local Health District..=".r-:. ' _ f <br /> j� C11nLot SizePM <br /> Job Address -1 ? �~ _ City <br /> —�iG -� Phone . <br /> Owner's Name <br /> Contractor's Name <br /> ` ense No. © Z•'S/ • Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL:LAEPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -SY�STEM 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 /> ❑ lndustrlal ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> '❑ Domestic/Private ❑ Gravel Pack ElTracy . Type of Casing Specifications <br /> ❑ Public ❑ Other ; ❑ Delta , Depth of Grout Seal Type of Grout <br /> ❑ irrigation ---Approx. Depth, ❑ Eastern �Surfaee-Seal Installed by3' <br /> H.P. , State,Work Done <br /> -. `,,Repair Work.Done ElType of Pump , _ <br /> Well Destruction OA W_611 Diameter Sealing Material {top 50'1 <br /> Dept h ` Filler Material 1Below 50') f <br /> W INSTALLATION.❑ REPAIR/ADDITION ❑ DESTRUCTION El (No septic system permitted i#public sewer is <br /> TYPE OF SEPTIC WORK: NEW k available within 200 feet.) q <br /> Installation Wil serve: Residence .Commercial Other <br /> 1a. <br /> Number of living units: ' Number of bedrooms -r "7 i <br /> Character of soil to a depth of 3 feet: '` �"" .. . —' VJate table depth <br /> Capacity <br /> SEPTIC TANK ❑ �T,ype/Mfg '^� No. Compartments <br /> Method of Disposal <br /> j PKG. TREATMENT PLT. ❑ r j; r"� <br /> Distance,to nearest: Well _� Foundation Property Line Tt <br /> off& Length of lines =- I Total length/size./ J <br /> LEACHING LINE �_N, — <br /> I¢ FILTER BED ❑ Distance to nearest: Well I Foundation ,— Property Line's <br /> SEEPAGE PITS Depth _.��� Size I f� L{ Number <br /> SUMPS G UiDistance to nearest: wW�ell Foundation ' Property Line <br /> DISPOSAL PONDS ❑- § "" _a - - ' <br /> Thereby certify that I have prepared this application and That the Will.be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sari Joaquin Local Health District.t }-'q-1—-'"" <br /> Home owner or licensed agent's signature certifies the following:"I cef*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."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance-of•the'w_ )kffor"ioh this permit is issued,I shall employ persons subject to workman's compensa- <br /> i tion laws of California." ' I 1 <br /> The appiic t mus�11 ffoor�al eq r in" ns. Complete drawing vera e•;.:; — <br /> Signed '�"- Title: .—� Date: C <br /> FOR UEP TMENT USE ONLY <br /> Date Area <br /> Application Accepted by , <br /> 1 n� <- <br /> ¢ Dat Final Inspection by Date <br /> Pit or Grout Inspection by f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi ' 69-3611 a Manteca 821-7104 ❑ Tracy V83r6385' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N, <br /> r , <br /> FEE AMOUNT DUE �. AMOUNT REMITTED H RECEIVED BY DATE PERMIT NO. <br /> INFO 1 <br /> + EH 13.24 REV,­10/831 <br /> E11.14-25 <br />