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APPLICATION FOR PERMIT J0013L4 rel#Sed. <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 /> Job Address 4Z f F City Lot Size 5119 tM <br /> Owner's Name Address 4antn Phone <br /> Contractor's NameLicense No. Phone . 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 Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing A Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material {Belo ') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION IV DESTRUCTION ❑ (No septic system permitted if public sewer is r <br /> available within 200 feet.) <br /> i 1n <br /> Installation will serve: ResidenceCommercial_ Other v! <br /> Number of living units: Number of bed oms f If <br /> Character of soil to a depth of 3 feet: Water table depth <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 1r No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation�-_ , . __ Property Line <br /> SE GE PITS Depth X I, Size Number � � <br /> SUMP Distance to nearest: Well 1QO.'_ Foundation Property Line. _ <br /> ISPOSAL 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 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."Contractor's hiring or subcontracting 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 workmen's compensa- <br /> tion laws of California." <br /> The applicant must call for all r ed inspections. Co late drawing on averse side. <br /> Signed37 <br /> Title: - /L Date: <br /> .FOR DEPARTMENT USE ONLY <br /> Application Accepted Date �i+'6 � ., ,_. Area M <br /> Pit or Grout Inspectio IV Date 11 B� Final Inspection Data <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ 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 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMW;N0. <br /> +EN 13-24(REV.10!931 <br /> EH 14-29 $ <br />