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41Q q_3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT D � 5Q <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 y <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 8EP 987 <br /> (Complete in Triplicate) u <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work t e�i �aquis <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and �� /5 <br /> Local Health District. i <br /> City o C Lot Size PM <br /> Job Address -- <br /> Address di� �� Phone <br /> Owner's Name _ <br /> /(23 7 3 Phone <br /> Contractor G� Address �'� �- /P-7 License No. \ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION .l] <br /> PUMP INSTALLATION - SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED_ USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> p <br /> .❑ Industrial El Open Bottom ❑ Manteca Dia. of WeWellExcavation Specifications <br /> (Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing-" <br /> T1'Public <br /> Ci Other CI Delta Depth of Grout Seal Type of Grout - <br /> I i Irrigation —.-Approx. Dept I I Eastern Surface Seal Installed by <br /> Repair,Work Done (k' Type of Pump <br /> H p . 1, State Work Done <br /> `'=' Sealin Material /top 50'1 <br /> Well Dee struction C] Weil Diameter g <br /> Depth Filler Material (Below 50') <br /> IE TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 IREPAIRIADDITION 1.1 DESTRUCTION I I available within 200 fe(No septic system et.) it public sewer is <br /> `Installation will serve: Residence; Commercial Other; <br /> Number of living units: Number of bedrooms „i r <br /> Character of soil to a depth of 3 feet: *' Water table depth <br /> f Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑F Method of Disposal <br /> Property Line <br /> Distance to nearest: Well Foundation P Y f <br /> k LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LlDistance to nearest: Well Foundation' Property tine <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 /> I The applicant call for all requir d inspections. Complete drawing on reveirse side. <br /> Signed X - itle:- - - - - Date:- X-3 r <br /> f FOR DEPARTMENT USE ONLY <br /> _ � t Date Area 0 <br /> I Application Accepted by r F{/ <br /> I <br /> Date Final Inspection by Data <br /> Pit or Grout Inspection by <br /> i <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AM T REMITTED -CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ei <br /> + EH 13-24(REV.i i tt 51 -, �O -3 <br /> EH 14-28 r <br />