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APPLICATION FOR PERMIT r� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> 1601 E. HAZEL i ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> b-1 (Complete in Triplicate) <br /> Application is hereby made to the San Jocatio is <br /> oun uinQrdinalnce No.District Health 549 for sewage or No. 1862 for well and/orinstall <br /> and the Rules and Regulationsd of the This San Joaqu n <br /> i0 made in compliance with San Joaquin County <br /> Local Health District. <br /> CJ , City ` tftLot Size PM <br /> Job Address <br /> Phone h <br /> Owner's Name O 7w, _ Address <br /> ' <br /> e Address License No. Phone <br /> Contractor <br /> PE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION [I SEWER <br /> REPAIR ❑ OTHER <br /> i DISTANCE TO NEARES : C TANK SEWER LINES <br /> DI <br /> SP0 PROP. LINE <br /> FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE ONSTRUGTION SPECIFICATIONS Dia. of Well Casing <br /> iii ❑ industrial ❑ Open Bottom ❑- ca %Dia. I-Excavation <br /> �7 ofCasing .�,Specifications. r <br /> ,, Cl Domestic/Private—❑,Gravel Pack r❑ Tracy,,__,,,,,-., 'Type g Type of Grout <br /> ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work L1 Type of Pump <br /> Sealing Material (top 50') <br /> Well ruction El Well Diameter 9 <br /> Depth Filler Material (Below 50'j <br /> +{ TYE SEC C1PTIWORK:-NEW INSTALLATION .REPAIR IADDITION ❑ DESTRUCTION <br /> POF available septic hit m,pefrmittted if public sewer is <br /> kr <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> 4 Character of soil to a depth of 3 feet: Na. Compartments <br /> SEPTIC TANK ElType/Mfg ` Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well r Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> j <br /> f SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> * f <br /> j 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 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." Contractor's <br /> hiring ct to workmanor sub-contracting <br /> racti compensa- <br /> Signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons <br /> tion laws of California." <br /> 4 The applicantq1ust c I for all requirodtinspecti ns. Complete drawing on <br /> reverse side. //1 j <br /> +L1/) Title: (/ Date: %U / <br /> + Signed <br /> FOR DEPARTMENT USE ONLY Date (J <br /> �—f 0 Area <br /> /1 <br /> � Application Accepted by <br /> ate <br /> Pit or Grout lnspectio <br /> Date Final Inspection by D <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 C1 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant=Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE NCKRECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED y <br /> F + EH 13-2 7 <br /> .I REV.1/65) . j lO� + � <br /> EH 1426 <br />