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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZ�,LT•,O,N'AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> .. <br /> r (Complete in Triplicate) <br /> /or install the work herein described.This <br /> cation is <br /> made <br /> in orris,compliance w made <br /> Sano the Joaqu nn Joaquin Local county Ordinance Nto.District549 for sewage or permit <br /> No 1862 for well ldpump and the Rules and Regulations of he Sang Joaquin <br /> made p , <br /> Local Health District. ;; . �k- <br /> a City of Size PM <br /> Job Address _--.- <br /> w Address ��/� J ;Phone I <br /> Owner's Name Q <br /> Contractor's Named License No. <br /> All 2-3 ' Phone 6 6— 16 z II <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT LJ/ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑, SYSTEM REPAIR OTHER ❑' <br /> 1 :DISPOSAL FLD. PROP. LINE ; <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br />+ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ±� I <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> [I Industrial v ' <br /> RT e <br /> ®'6omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> 4 p Public ❑ Other 171 Delta Depth of Grout Seal <br /> ❑ Irrigation /---Approx. <br /> of Pump Approx. Depth El stern SurfacJLSeal Installed by <br /> Repair Work Done <br /> 2f �t H P ,S State Work Done <br /> ' Well Destruction ❑ Well Diameter Sealing Material It <br /> Depth Filler Material (Belo -' _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Noavaseptic system peithin rmtted if public sewer is <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: _ No. Compartments <br /> ❑ Type/Mfg SEPTIC TANK Capacity <br /> .,i�• � Method of Disposal: <br /> i PKG. TREATMENT PLT. ❑ Pro a Line ` <br /> Distance to nearest: Wel Foundation p rtY <br /> I r 'z � Total lengthlsize <br /> 1 LEACHING LINE ❑ No. & Length of lines Property Line--, <br /> FILTER BED ❑ Distance to nearest: I Foundattiioon <br /> � f . <br /> Size Number <br /> SEEPAGE PITS 11 Depth Property Line <br /> SUMPS ❑ Distance to nearest: Well Fou ation " <br /> DISPOSAL.PONDS <br /> __ "an <br /> 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 /> that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies-the following: "I certify <br /> employ any per ch manner as to become subject to workman's compensation laws of Calffornia."Contractor's hiring or sub-contracting signature <br /> cartes the IVowing:"I ertify that in the perfor a of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws f California." <br /> The ap icant m r all re e i plate drawing on r side. <br /> I Title: � Date: <br /> Signed i <br /> OR DEPARTMENT USE ONLY <br /> Date 5 Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> F-1 Stk 466-6781 11 Lodi 369-3621 C] Manteca 823 71D4 ❑ Tracy 8&5-63%' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> ffFC CK RECEIVED BY DATE' PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED ASH M <br /> +FEN ts2eIREV.mrsal C 0b ' , 5� �t- G(.� <br /> EH 1426 - <br />