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APPLICATION- FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH. DISTRICT <br /> 1601 E. HAZE'LTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES`1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)' - , ry <br /> work Application is hemade <br /> San Joaquin County Ordinalnce No.District Health 549 for sewage or(No. 1862 for t to construct and/or <br /> atnd the Role and hereinR Regulations of he San(Joaquin <br /> made in compliance ` <br /> Local Health District. <br /> r Cit rr C XT-0+�" Lot Size PM <br /> Job Address <br /> Owner's Nam Q� are6s 1 <br /> V eA/Q Phone <br /> p 1 ��` OX License No. I Phone <br /> 3 I- 3a� <br /> ICoOnt-r etch ` AT wl� Address <br /> TYPE OF WELL/PUMP: <br /> EW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION e E -` F� SYST•EM'REPAIA (] OTHER ❑ <br /> ! SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k DISTANCE TO NEAREST: SEPTIC TANK ® PiTSISUMPS <br /> l FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE --'TYPE-OF WELL x--PROBLEMAREA-.CONSTRUCTION 5PECIF1CATlONS - pia. of Well Casing <br /> ❑ Industrial i 171 Open Bottom Ll Manteca Dia. of Well Excavati��.- Taga Specifications <br /> Domestic/Private ❑ GreType of Casing <br /> vel Pack ❑ Tracy i r' Type of Gr t <br /> ❑ Public.K ! Ll Other Q Delta DeptFi'of Grout Sea! 'r �s <br /> ❑ Irrigation . J4pprox. Depth D Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P `=i "' 'State Work Done <br /> Well Destruction ❑ Well Diameter ­Sealing-Material'{top 501 <br /> f" <br /> f < _ - .- Filler Material-(Below 50'1 <br /> Depth n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTIONS_ availableNo lw thin 20tem 0 feett'ed if public sewer is f"%1 <br /> Installation will serve:'. Residence Commercial f-ther I O <br /> Number of living units: II Number of-bedroo ms f' c+w•^Water table depth <br /> Character of soil to a depth of 3 feet:' <br /> �' CapacityNo. Compartments <br /> SEPTIC TANK ❑ 'Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> i Distance,to nearest: Well Foundation <br /> r ' <br /> LEACHING LINE Q � Total length/size <br /> II No. & Length of lines Property Line <br /> FILTER BED a ❑ I.Distance to nearest: Well Foundationn <br /> " -- ;� Number <br /> j SEEPAGE PITS I ❑ r Depth Size Property Line <br /> SUMPS :❑i1: Distance to nearest: Well" Foundation <br /> DISPOSAL PONDS ❑ y 'I <br /> I hereby certify that I have prepared this'application and that the work will be done in accordance with San Joaquin county o--rdinances, 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 nore <br /> t <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contraceorso'snshiring <br /> sub subject t workman'seompensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ p 1 <br /> tion laws of California."' <br /> The applicant rnus c II#o all re uired inspections. Complete drawing on reverse 'd . <br /> Title: Date: <br /> Signed <br /> + FOR"DEPARTIUENT USE ONLY <br /> f Date `Z Area <br /> ` Application Accepted by iI <br /> I -Pit or Grout Inspection b Date <br /> Final Inspection by Date <br /> e6 <br /> Additional Comments: J <br /> ❑ 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 952011 <br /> CK RECEIVED BY DATE' PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO g5-[`�5 b io <br /> +EH 13-24(REV.1/851 <br /> EH W26 <br />