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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1.4 <br /> 6 City Lot Size r PM <br /> ,job Address -1713- <br /> Phone �� f <br /> Owner's Name i Address <br /> Contractor <br /> Address UIC se Noy--.- - �y�"-Phone <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMEN.T��'��' �ESTRLiCT1O <br /> PUMP INSTALLATI N ❑ _.SY-SS�hf�RE7n OTHER ❑ <br /> i` EWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> UNDATION — AGRICULTURE WELL j-- OTHER WELL PITSISUMPS,�C� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r?0� <br /> en Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial P <br /> an_D Specifications ,L <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casingf� 6 <br /> 1 1 Other Ll Delta Depth of Grout Seal _ .cw H Type of Grout1_54e�_ <br /> ["1 Public� _ <br /> rlgation —_Approx. Depth l 1 Eastern Surface Seal Installed by [ <br /> 'Repair Work Done LJType of Pump H.P. State Work Done w <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material,RBelow 50_) -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION { I DESTRUCTION i I (No septic system <br /> rented if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Scity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. l;, Length of lines Total length/size <br /> FILTER BED ❑ Distance,_to nearest: W Foundation Property Line <br /> SEEPAGE PITS l l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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 laws, an <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 sh _ of <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractot'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 /> The applicant mu fo d ins pe s. Complete drawing on reverse side. f <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> . � r � Area <br /> Application Accepted by Data <br /> Pit ar to t inspection by <br /> DateFinal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ TM; Da <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Ha009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED CK CASHDATE. PERMIT NO. ��ZC <br /> INFO 0. ()o <br /> � � <br /> + EH 13-24IREV.r/n5) 0. rV � <br /> EH 14-26 <br />