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APPLICATION FOR PERMIT <br /> 1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1641 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> f 4 PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ct and/or install the work herein described. This application is <br /> fl Application is hereby made to the San Joaquin Local Health District for a permit to constru <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or NoPC .for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 4 I <br /> 4 City Lot Size PM <br /> Job Address f t I <br /> j Phone <br /> Owner's Name W. ress <br /> - . D <br /> S , <br /> License No. Phon <br /> Contractor dresse <br /> TYPE OF WELL/PUMP: <br /> NEW 1gVE L ❑ W REPLACEMENT ❑ DESTRUCTION 171 <br /> PUMP INSTALLAT[ON <br /> SYSTEM REPAIR O OTHER <br /> SEWER LINES DISPOSAL F PROP. LIFE <br /> DISTANCE TO NEAREST: SEPTIC TANK WELL PITS/SUMPS <br /> ! FOUNDATION AGRICULTURE WELL <br /> k INTENDED USE TYPE OF-WELL PROBLEM AREA CON TION SPECIFICATIONS Oia. of Well Casing <br /> I ❑ Oen Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial P Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack y Type of Casing <br /> F] Public f.3 Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> I Irrigation ox. Depth l I Eastern e Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ ype of Pump <br /> Well Destruc' ❑ Well Diameter Sealing Material [tap 50') <br /> Depth Filler Material {Below 50') <br /> } TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION I ! DESTRUCTION availablIN <br /> el'within 200 feestem t.) if public sewer is <br /> Installation will serve: Residence F Commercial_ Other <br /> L, Number of living units: Number.of bedrooms ---"`— am <br /> �" Water table depth <br /> Character of soil to a depth-of'3 feet: / <br /> apacit No. Compartments <br /> C <br /> t SEPTIC TANK Type/Mfg y – <br /> ­iMethod of Disposal <br /> PKG. TREATMENT PLT�0 _ <br /> Distance t~o rte`arest:------Well_ --Foundation Property Line <br /> 3 . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> I <br /> SEEPAGE PITS l 1 Depth Size <br /> Number <br /> SUMPS ,� [_I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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, 1 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 /> f 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 /> I tion laws of California." <br /> The applicant must all re ed inspections. Complete drawing on arse side. <br /> Signed X Title: Pate: <br /> '�7lYJ�FOR DEPARTMENT USE ONLY <br /> y�� <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection <br /> pate Final Inspection-by—� Y DateC�G Q <br /> 1 s <br /> Additional Comm <br /> ents: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 11 Manteca 823-7104 fl Tracy 835-6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> EEE CK RECEIVED By DATE PERMIT NO. <br /> jZ!! AMOUNT REMITTED CASH <br /> . EH 1 <br /> 3-24 1REV.1/n 51 INFO <br /> EH 14-2e <br />