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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZI=L i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> No.549 for sewage or No. 1862 for well!pump and the Rules and Regulations of the San Joaquin <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 /> pP <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. PM <br /> 3 <br /> Citymffd—��?!tl Size <br /> Job Address pp rCs �c <br />` pfrl\ U, one Gres; one <br /> E Owner's Name r q C(j 7 7 <br /> Phone <br /> �QJC. License No. <br /> Contractor's Name WELL REPLACEMENT Q DESTRUCTION <br /> ' TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP. LINE <br /> EWER LINES PITS/SUMPS I � <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE JL� OTHER WELL <br /> FOUNDATION <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �� Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> ❑ Tracy Type of Casing Type of Grout <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Delta Depth of Grout Seal <br /> ❑ Public C1 Other <br /> �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'? <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW IN57ALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (Nailabllelwithin 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> k Character of soil to a depth of 3 feet: capacity— No. Compartments <br /> I SEPTIC TANK ❑ Type/Mfg Method of Disposal { <br /> PKG. TREATMENT PLT. d Property Line j <br /> Distance to nearest: Well Foundation p ' <br /> Total length/size <br /> LEACHING UNE ❑ No. & Length of lines Foundation Property Line <br /> s <br /> FILTER BED ❑ Distance to nearest: Well <br /> i' Size Number ; <br /> SEEPAGE PITS ❑ Depth Foundation Property Line <br /> t <br /> SUMPS ❑ Distance to nearest: Well i <br /> DISPOSAL 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 aws, and <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> Home owner or licensed agent's signature certifies the following: "I cer en's ify that <br /> in the <br /> laws oof Cale of tniahe Contractor's�hir ng'or sub-contracting issued, <br /> signlatuore <br /> employ any person In such manner as to become subject to worka work <br /> pe <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 co pensa <br /> E tion laws of California." 1 <br /> f The applican ust call for all r ired ' ct.one Complete drawing onreverseside. <br /> � Title: L'-Q�� Date: 3 <br /> Signed <br /> rze­ FOR DEPARTMENT USE ONLY <br /> �! Area <br /> Application Accepted by Date —� <br /> P Final Inspection by Date <br /> Pit or Grout Inspection by �+�c Date <br /> k � _ " � r � Q �tr♦�!~C� <br /> Additional Comments: <br /> G -rcf r l K i^@.Vv Ve Gt-r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> + CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. $q � <br /> i INFO `5�' – • <br /> yy����a v�-- <br /> j +EH 13-24(REV.10!83) Q�O�Q(� L <br /> cu IA-79 - <br />