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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DIST, T <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 />tr <br />Job Address ll fOa l ate/ q/// i'M" r;r„J • 1�n t .,• c;,® loo a C . otu <br />�W `� YGC �r f' �� "' p Iyl�i <br />Owner's Name <br />� Address Phone <br />ContractorlJ{A` <br />// ` w Address �® /`��N_ License No. �a�`-3 Phone 2421f 0221 <br />TYPE OF WELL/PUMP: <br />NEW WELL $ZWELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL Q / PITS/SUMPS <br />INTENDED USE <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br />Cl Industrial <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />1�4-D�o ti /Private <br />Gravel Pack ❑ Tracy Type of Casing 7- itP✓L 5'Specifications <br />F1 Pit tilich`?"7 <br />n Other Ll Delta Depth of Grout Seal 20 Type of Grout 1 !% <br />I I Irrigation <br />Ab -'Approx. Depth I I Eastern Surface Seal Installed by r e/r • . <br />Repair Work Done U <br />Type of Pump H. P. State Work Done _ <br />Well Destruction ❑ <br />Well Diameter Sealing Material Itop 50') <br />Depth Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: <br />NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: <br />Residence ^ Commercial _ Other <br />Number of living units: <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. <br />El �t Method of Disposal <br />distance to nearest: Well Foundation Property Line <br />1tV <br />LEACHING LINE V� <br />❑ No. & Length of lines Total length/size <br />FILTER BED A4�( <br />❑ Distance to nearest: Well _. Foundation Property Line <br />SEEPAGE PITS <br />I I Depth Size ____,__.___ V _ Number _. <br />SUMPS <br />L] Distance to nearest: Well.-- Foundation.—--- Property Line <br />DISPOSAL PONDS <br />L-1 <br />• - T ­ r . — �a P aPa� imb dNpacduon ano tnat the worK W111ue cone 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, 1 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 11 req 'red inspections. Complete drawing on reverse side. B L <br />Signed X Title: �Lcd—__F---/l `}�Y-"fZ-1�j ¢ 7 AT <br />F--- ate: <br />_ C f� n EPARTMENT USE ONLY c� <br />Appli ccepted by ��1� v� C� Datea� `-' Area <br />Pit or rout spection by Date �i-zQ IJV Final Inspection by c',>�,�- Date <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manta 823-7104 ❑ Tracy 835-6385 S �p <br />Applicant - Return all conies to: iro mental Health Permit/Services 1601 E. Hazelton Ave., P.O. 2009, Stk., CA 95201 <br />�.EH 13.241REV. i/es <br />EH 14.26 <br />IF EE O <br />MOUNT DUE <br />AMOUNT REMITTED <br />C 8H <br />RECEIVED BY <br />DATE PERMIT'NO. <br />7�� <br />