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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUE <br /> (Complete in Triplicate) <br /> ermall the work <br /> n described, This <br /> cation is <br /> Application is hereby made no toha u n Gounty OLocalne Health District <br /> for sewage or 1No�1862 forcwellldpump and the Rules and rRegulations of the Sant Joaquin <br /> made in compliance withSa „ U <br /> Local Health District. 104141j0 • / <br /> ''1' city Lot Size PM <br /> i <br /> Job Address <br /> Phon ��a✓VV <br />`. Address <br /> Owner's Name <br /> S 1 <br /> License No. Phan <br /> Address <br /> i Contractor Address <br /> %, <br /> El . <br /> is NEW WELL ❑ WELL REPLACEMENT ❑ 141 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR L3OTHER ❑ <br /> - PUMP INSTALLATION ❑ <br /> LINES ��--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SESEWER SEPTIC TANK PITS/SUMPS <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 44 INTENDED USE -� TYPE OF WELL Pk308LEM AREA CONSTRUCTION SPECIFICATIONS <br /> Well Excavation Dia. of Well Casing <br /> r ❑I,Open Bottom ❑ Manteca Dia- of We <br /> ❑ industrial Specifications <br /> ❑.Domestic/Private ❑ ❑ Tracy Type of Casing <br /> !Gravel Pack Depth of Grout Seal Type of Grout---- <br /> P: <br /> rout \\\.7 <br /> f l Public P:Other C1 Delta i� <br /> ..Approx. Depth I I Eastern Surface Seal Installed by <br /> r I 1 Irrigation Ii H.P. State Work Done _ <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Wiell Diameter <br /> Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l.! DESTRUCTION I I (No septic system permitted if public sewer is <br /> � � available within 200 feet.l <br /> Installation will serve: .Residence— Commercial_ Other # <br /> f r ` <br /> Number of living units: ... Number of bedrooms -.-- Water table depth <br /> I Character of soil to a depth of 3 feet: ^-' No- Compartments <br /> SEPTIC TANK 01 Type/Mfg r Capacity <br /> W Method of Disposal <br /> PKG. TREATMENT PLT. ❑I in Property Line <br /> Distance to nearest: Well Foundatio <br /> r No. & Len Length of lines 'Total length/size } <br /> LEACHING LINE g dr Propertytine ; <br /> FILTER BED Distance to nearest: Well� — Foundation 1�.- a <br /> ` Size Number <br /> l SEEPAGE PITS I i� Depth Property Line <br /> SUMPS Ll l Distance to nearest: Well Foundation p rtY <br /> DISPOSAL PONDS D. - <br /> hat i have this application and that the work will be done in accordance witfi Sa�Joaquin county ordinances, state laws, and <br /> 1 hereby certify t <br /> i rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the pe r#ormance of thework for which this permit is issued, I signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California. ploy ceosonslsubjecring rt tobworkman's gcompen`sa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p <br /> ktion laws of California." �II = { <br /> The applicant must call fo'all required inspections. Com ete drawing on reverse side. <br /> Title: 1 Date: <br /> �. Signed X - .. <br /> FOR DEPARTMENIVUSE ONLY <br /> E w Date l � Area <br /> Application Accepted by <br /> I Date Firial Inspectieby � Date <br /> I� on <br /> Pit or Grout Inspection by i <br /> Additional Comments:_ j - <br /> Q Stk 466-6781 a'Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. fox 2(109, Stk., CA 95201 <br /> �' NO. <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT <br /> I F L <br /> + EH53-241REV.IIHti) ,0o <br /> 00 <br /> `r EH 1428 <br />