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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA :. <br /> Telephone (209) 466-6781 1 (� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" <br /> _:_;' (Complete in Triplicate) <br /> wo <br /> rei <br /> This <br /> Application is herebymadithe <br /> San Joaquin he San <br /> nJo Couaquin nty Ordiis <br /> nance No.Districtal Health 549 for sewage or permit <br /> No. 1862 forcwell and/or <br /> pump install <br /> nd the Rules and Reggulat�of the San'Joaquin <br /> in <br /> made in compliance <br /> Local Health District. <br /> Job <br /> Address <br /> Lot Size PM <br /> C1 Q <br /> J o1 . T--" <br /> 1 . Phone <br /> Address <br /> 666r � <br /> Owner's Name <br /> Phone `ytT <br /> Contract <br /> Address License No <br /> DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: { N WELt ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION,0 SYSTEM REPAIR ❑ <br /> SEWER LINES L FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK . y AGRICULTURE OTHER WELL PITS/SUMPS <br /> I FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS <br />€ [--1 Industrial ❑ Open Bottom--- anteca�-- ion pia. of Well Casing <br /> Dia• of Well Excavat <br /> ❑ Tracy Type of Casing Specifications[3Domestic/Private ❑ Gravel Depth of Grout Seal Type of Grout <br /> ❑ Public er ❑ Delta <br /> ❑ lrri - n --eApprox. Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repai or Done ❑ Type of Pump Sealing {top 50'1 <br /> 0Diameter <br /> Well Destruction {Well Diamng Ma <br /> eter <br /> f Filler Material-Welow 50') V <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCT�ION/alvailable3withine200 rmitted'rf public sewer is <br /> Installation will serve: Residence Commercial, Other <br /> Number of bedrooms 1 <br /> Number of living units: ` Water table depth <br /> j Character of soil to a depth of 3 feet: � Ca�city >sO� No. Compartments, <br /> { SEPTIC TANK TypelMfg <br /> f I Method of Disposal. <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> ( ` <br /> `- Total length/size <br /> LEACHING LINE ❑ No. &'Length of lines - _ �' Property Line ' <br /> {� Distance to nearest: Well Foundation <br /> FILTER BED rM1y <br /> ❑ Depth Size - Number <br /> r SEEPAGE PITS ! Foundation Property Line <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS 0 ' Z � 1 <br /> � ork'will be done in accordance with San Joaquin county ordinances, state taws, and <br /> I hereby certify that I have prepared this.application and that the w <br /> r rules and regulations of the San Joaquin Local Health District. work for <br /> Home owner or licensed nsuch manna signature <br /> as to becomes the folbject lowing: <br /> "I Gerd ipensation laws operformance <br /> California."Contractor's <br /> lhir hiring or sub-contracting lsignatushall re <br /> employ any pe <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall emp,oy persons subject to workman's compensa- <br /> tion laws of California.,, <br /> The applicant st call for.all re iced inspections. Complete drawing on reverse side. , ��f%en <br /> Title: _—�'�• f Date: y 1 <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> 1� ! y Date �'� Area <br /> Application Accepted by Date ] <br /> 4 Date, '� Final Inspection by <br /> i Pit or Grout Inspection <br /> Additional Comments: <br /> ❑ St 46C-Ml ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy835-OMStk., CA 95241 <br /> Applicant Return all copies to: Environmental Health Permit/Servics 1601 E. Hazelton Ave., P.O. Box 2009, <br /> 1 <br /> k�f <br /> CK RECEIVED BY DATE PERMM NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 1324(REV.i/s 5) <br /> EH 14-28 "`� _ <br />