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rc <br /> APPLICATION FOR PERMIT C7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> l <br /> (Complete in Triplicate) e work <br /> . This <br /> Application is hereby made to the San icon y ocat"On is <br /> rd nanee No.549 for sewage or iNo- 1862 for we l/pumto construct and/or1p and the Runes and herein <br /> gulations of the Sanl Joaquin <br /> made in compliance with San Joaquin tY <br /> Local Health District. /� / <br /> lvLot Size PM <br /> s�* 'TAG A <br /> LI y s (AACity <br /> Job Address <br /> 2 Z 4�. i/+..i/1/e/L Phone , <br /> ✓ Address <br /> Owner's Name <br /> Se /4-1 Address [ License No. Phone_ <br /> ContractorDESTRUCTION ❑ <br /> i NEW WELL ❑ WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES _ DISPOSAL FLD. POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -- AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack i Depth of Grout Seal Type of Grout Cl Other Cl Delta _ <br /> l'1 Public Ot <br /> I Irrigation pro Depth I.1 Eastern Surface Seal Installed by <br /> f <br /> e H P State Work Done— <br /> Repair Work Done ❑ Tjp� P mp"0% <br /> Well Destruction ❑ Well mer Sealing Material {top 501 <br /> Dep Filler Material (Below 501 <br /> TYP! OF SEPTIC WORK:' E I STAL T 1 REPAIR/ADDITION l 1 SCTI (No septic system permitted if public sewer is <br /> Tf3UON <br /> available within 200 feet.) <br /> O <br /> t installation it�serve: o merciaal ther <br /> silence \ <br /> Number of g it� N r bed oo s Water table depth <br /> Characterof,'oil a depth of f :et <br /> f Of ,Capacity No. Compartments <br /> SEPTIC TANK ❑ T e/ g Method of Disposal <br /> I PKG. TREATM T P ❑ <br /> �rj� -Foundation Property Line <br /> # Istan to r1Qa�r�st: Idl <br /> LEACHING LINE ❑ en ti es <br /> Total length/size <br /> nearest: Foundation Property Line <br /> FILTER BED ❑ is li A <br /> x <br /> SEEPAGE PITS I i Depth' f Size NumberPropertyLine <br /> SUMPS <br /> Ll Distance to nearest Well Foundation y <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 /> r <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 $hall 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: u certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> k tion laws of California." <br /> The applicant must call for quired inspections. Complete drawing on reverse side. r <br /> Date: <br /> Title: <br /> Signed X ; <br /> FOR DEPARTMENT.USE ONLY <br /> F <br /> Date { Area <br /> Application Accepted by ; I <br /> r E Date <br /> Date_ Fina jnspection by <br /> Pit or Grout inspection by <br /> Additional Comments: <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823- 104 ❑ Tracy 835 6385 <br /> j Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95241 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS (� ( <br /> INFO <br /> ♦.EH 13-24(REV.1/H 5) <br /> EH 11-26 <br />