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tv o w1�LL <br /> APPLICATION FOR PERMIT <br /> a, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' s <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. � <br /> r. <br /> {Complete in Triplicate).. <br /> i-N <br /> TWs <br /> cation is <br /> all the work herein <br /> Application is lance made <br /> Sano the Joaqu nn Joaquin County OrdinanceNo. <br /> No.District Health 549 for sewage or permit <br /> 1862 for cwell/pump and the Rules and Regulations of he Sant Joaquin <br /> made in compliance <br /> Local Health District - 1 <br /> - r. <br /> City Lot Size PM <br /> Job Address <br /> �7�} <br /> Owner's Name <br /> dress . ."Phone (Owl <br /> Phone <br /> Contractor Address _ <br /> ' License No. (Ai <br /> TYPE OF WELL/P P: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP. LINE <br /> ELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL O <br /> IYPE OF WELL PROBLEM AREA CONS ION SPECIFICATIONS <br /> ❑ <br /> e Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom an r <br /> Type of Casing Seci�fic�tions <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr r T e of Grout <br /> ❑ Public El Other Delta, Depth of Grout Seal yp <br /> no <br /> ❑ Irrigation �ppro epth ❑ Eastern(,, Surface Seal Installed by <br /> Pump H.P. State Work Done <br /> Repair Work Done [I Ty _ <br /> Well Destruction ell Diameter Sealing Material stop 5D'1 <br /> Depth' 'Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW#INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION VT <br /> (No septic sy tem smutted if public sewer isava , <br /> i I <br /> Other <br /> Installation will serve: Residence, Commercial f , <br /> Number of'living units: Number of bedrooms Water table depth . <br /> ' Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg <br /> a Capacity_ No. Compartments <br /> r, � Method of Disposal <br /> PKC. TREATMENT PLT- ❑ i 1 Property Line <br /> Distance to nearest: Well Foundation <br /> s i <br /> Total length/size <br /> LEACHING LINE ❑ No!&Length of lines Property Line <br /> FILTER BED - ❑ Distance to nearest: Well Foundation <br /> a.-- « Number <br /> 1 SEEPAGE PITS ❑ Depth rvSize <br /> SUMPS <br /> ❑ 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, 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 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." V ti M <br /> The applicant-must call for all requ''i id inspections. Complete drawing on reverse side. <br /> -- - Date: <br /> f X <br /> Signed Tule. _ —k <br /> g t { � } t .� <br /> F Q <br /> DEPARTMENT USE ONLY <br /> pate Area <br /> Application Accepted by <br /> Date Final inspection by Pate <br /> Pit or Grout Inspection by <br /> c7 <br /> Additional Comments: lie, <br /> f ❑ Stk 466-6781 C.Lodi 369-3621 C3Manteca 823-7104 El.Tracy 835 6385 <br /> F Applicant- Return all copies to: Environmental Health'Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> i <br /> -' RECEIVED BY DATE PERMIT N0. <br /> a ,FEE AMOUNT DUE AMOUNT REMITTED <br /> 1 INFO <br /> + EH 13-24(REV. x s) �S � Q p 1 Q •. , <br /> EH 14-26 - - - <br />