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APPLICATIONTOR PERMIT <br /> ,.�. SAN JOAQUIN.LOCAL HEALTH DISTRICT , <br /> I <br /> 1601 E. HAZE T ON AVE.,;STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 11 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 /> //V 2 C. 142 F City G/C� Lot Size PM <br /> Address <br /> `� 4 <br /> Job A .. <br /> �' iidress Phone �G 3-76 <br /> Owner's Name , <br /> i <br /> Contractor Address License No. Phone_ <br /> j TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION L OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC <br /> Dia. Casin <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. o cavation g <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing--:­-. Specifications <br /> j <br /> [I Public ❑ Other Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation rox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Don Type of Pump H.P. State Work Done <br /> Well ction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence° Commercial, Other <br /> Number of living units: Number of bedrooms - <br /> character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I O Method of Disposal <br /> PKG. TREATMENT PLT. j <br /> Distance to-nearest:­-Well­—-.—Foundation - - —Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑, Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth <br /> Size Number r <br /> SUMPS ❑ Distance to nearest: WellFoundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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."- <br /> 'f <br /> alifornia."_ -.-- <br /> The applicant must all far all re fired i p' tions. Complete drawing on reverse side. <br /> I Title: Date: f <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date <br /> Application Accepted by <br /> Pit or Grout Inspection b Date Final Inspection by Date-0 <br /> Additional Comments: r �� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 J <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> •CK <br /> FEES-�.AMOUNT DU z"'�'"""-AMOUNT REMITTED "' RECEIVED BY` DATE PERMIT NO. <br /> + EH 1324(REV.1/85) <br /> EH 14-28 <br />