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APPLICATIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 112091 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 /> Job Address 1,54% City Lot Size X1,0 ACE-iS PM <br /> Owner's Name Skt. t Address Phone <br /> Contractor's Name 9WgMti SINNS License No. �96 �� �'�° [� •Phone -16 6 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 AGRICULTURE WELL OTHER WELL PITS/SUMPS -� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Weil Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications. <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump N.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 ` <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION R DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence X_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> t <br /> Character of soil to a depth of 3 feet: L6 ANI Water table depth 1 <br /> SEPTIC TANK ❑ .Type/Mfga f Capacity No. Compartments M` <br /> PKG. TREATMENT PLT. F7I Method of Disposal <br /> { , f s <br /> Distance to nearest: Well Foundation Property Line <br /> w <br /> LEACHING LINE I; No. & Length of lines I - q6, Total length/size <br /> FILTER BED ❑ Distance to nearest: Well. - +Foundation Property Line ..— <br /> , . °7O 4 , <br /> SEEPAGE PITS •0Depth _ Size re= Number <br /> r i <br /> SUMPS 012 Distance to nearest: Well &P7 Foundation J26..� Property Line <br /> DISPOSAL PONDS ❑ s ,}- ` <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 District.--- - T.�n -- R•� <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." Contractors 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." r <br /> The applicantoust cal r all required inspections. Complete'drawing on reverse side. <br /> Signed Date:Title: c <br /> f b - - .- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r Area t✓ <br /> Grout Inspection by Date Final Inspection by Date <br /> Additional Comments:' <br /> t5',�k 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> —.F—F—EE—T AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY " DATE PERMITNO. <br /> INFO CASH l } <br /> +EH 13-24(REV. ff <br /> 101831 <br /> EH 1428 <br />