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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.-HAZELTON AVE., STOCKTON, CA A " <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES.1 YEAR FROM DATE ISSUED <br /> / -7� a G <br /> I, (Complete in Triplicate) t t C <br /> all the work herein <br /> . This <br /> cation is <br /> Application is herabyN th Sano the San Joaquin County Ordinance No.Districtuin Local Health 49 for sewage or permit <br /> No. 1862 for well/pump atnd the Rules and Regulations of he San Joaquin <br /> made in compliance <br /> Local Health District. J` c1 <br /> City ,�'rccx./ i _ Lot Size .R, ' aCrcS PM <br /> Job.Address.: <br /> _ 26OA9 �' rfer te_. SCak-"Phon'e <br /> Owner's Namur r Address <br /> co <br /> ;Contractor's Name License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El OTHER <br /> L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 171r <br /> SEWER LINES -DISPOSAL FLO. PROP:LINE k <br /> DISTANCE TO NEAREST: SEPTIC TANK � s <br /> FOUNDATION AGRICULTURE WELL-' I OTHER WELL PITS/SUMPS <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> pia.,of Wel! Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r <br /> Type of Casin Specifications <br /> ❑ Domestic/Private Ll Gravel Pack LI Tracy yp g T e of Gr"t <br /> LI-Public -� ID Other <br /> ❑ Delta Depth of Grout Seal Type s <br /> tY❑ irrig tions «�tr �Appraic:,Depth ❑ Eastern Surf Seal installed by <br /> Repai w rk-DoneD a Type of Pump <br /> H.P. <br /> ---- <br /> ate Woik.Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> 05Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW-INVZL—TION REPAIR/ADDITION❑ DESTRUCTION ❑ (Nail eptic system <br /> in emitted ifr <br /> rpublic sewer isk <br /> 01 <br /> Installation will terve Residence Commercial Other <br /> Number of living units:_J_ Number of bedrooms Water table depth ` <br /> Character'.osoil to'a depth of 3 feet:. <br /> Type' `f +a Capacity 6 No. Compartments <br /> I "SEPTIC TANK TypelMfg r , <br /> Method of Disposal <br /> ,i PKG. TREATMIENT PLT. ❑ _ <br /> Distance to nearest: Well 5 d Foundation Property Line ' <br /> t ©f �� Total length/size <br /> " <br /> LEACHING LINE No. & Length of lines /fir <br /> F 1 l FILTER BED' L3 Distance to nearest: Well Foundation y' Property Line <br /> SEEPAGE PITS ❑ Depth Size — Nyrmber <br /> i .It Property Line <br /> SUMPS Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> F I hereby certify that I have prepared this application and that the work will be done in accordance with�5an Joaquin county ordinates, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> t Home owner or licensed agent's signature certifies the following: "I certify th'at,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 compensetion 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 permitF)isissued„1 shall employ persons subject to workman's compensa- <br /> tion laws of California.” f <br /> The applicant must call all requir d in.pec;tions. Complete drawing on reverse side. <br /> Signed =` Title: <br /> f <br /> • Date: <br /> ( FOR DARTMENT USE ONLY 1 <br /> y /° / '..t> rt• Date 0 Area <br /> Application;Aecepted-by r L/" .,,, a,. r s' <br /> Pd'or Grout inspection by -t � •Date �' Final Inspection by t Date <br /> Additional Comments: <br /> ❑ Stk 466.6761 ❑ Lodi 369-3621 —El-Mantecar823z7104 (D Tracy-835-6385 - y <br /> Applicant- Return all copies to: Environments! Health Permit/Services 1601 E. Hazelton Ave., P.O.16— <br /> Applicant <br /> CA.95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY PATE PERMIT'NO. <br /> INFO <br /> -P--w+.-.T..�E�+a•. <br /> M •_ N —f f- f 8'4�157 <br /> +EH`t3�24-OfEV.10/831 -....+..���� <br /> e «._EH 1426 <br />