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APPLICATION FOR PERMIT 1, fo <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'Y.EAR FROM DATE ISSUED <br /> Application is heieb (COmplete in Triplicate) <br /> Y made to the San Joaquin Local Health District for a permit to construct and/or install the <br /> made in compliance with San Joaquin Cnun <br /> Local Health District, tY Ordinance No, 549 for sewage or No. 1862 for well! work herein described, This application <br /> pump and the Rufes and Regulations of the S ns <br /> Job Address <br /> t City Lot Size �aCA-�Owners Name PM <br /> Address LA 6 ' <br /> Contractor Phone <br /> TYPE OF WELL/PUMP: Address �p7 ' <br /> License No <br /> NEW WELL ❑ WELL REPLACEMENT ❑ Phanrt��r� <br /> " u _ PUMP INSTALLATION LlDDESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN _ SYSTEM REPAIR ❑ <br /> K , <br /> - —���SEWER LINESJ OTHER ❑ <br /> FOUNDATION ——�— DISPOSAL FLD. PROP. LINE T"" <br /> -AGRICULTURE WELL01 <br /> INTEIVDED.USE--- ,.TYPE OF WELD ,07HER WELL_ PiTS/SUMPS <br /> �_,PROBLEMy ARA CONSTRUCTION SPECIFICATIONS_ <br /> ❑ Ihdustrial Q Open Bottom <br /> ❑ Domestic/Private ❑ Manteca 17ia. of Well Excavation <br /> Q Grave! Pack ❑ Tracy T Dia. of Well Casing <br /> i i Public f) Other, Type of Casing <br /> Delta Depth of Grout Sea! Specifications <br /> I i <br /> Irrigation Type of Grout i <br /> Repair Work Done L-1Type of PiimpApprox, Depth i I Eastern Surface Seal installed by <br /> Well Destruction ❑ Well Diamet&'-,4! 4��._,�_ H.P. State Work Done <br /> Sealing Material drop 50'1 <br /> Depth 's - Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR <br /> /ADDITION f I DESTRUCTION [ 1 dNo septic system <br /> Installation will serve: Residence A permitted if public sewer is <br /> Commercial available within 200 feet.)- i <br /> Number of livingunits: 1 Other <br /> Number of (rooms } <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 'Type/Mfg Water table depth <br /> PKG. TREATMENT PLT, ❑ Capacity—� 0 No. Compartments <br /> Distance to nearest: Vtieif Method of Disposal <br /> Foundation� Property.Line �. <br /> LEACHING LINE <br /> No. & Lengthoflines <br /> FILTER BED ❑ Distance to nearest: Well—1-_�_ notal length/size K <br /> DFoundation Property Line <br /> r <br /> SEEPAGE PiTS � I <br /> Depth Size <br /> SUMPS CI Distance to nearest: Wefl umber \ 7 . <br /> DISPOSAL PONDS r Foundation <br /> ❑ � ' ` Property,Line <br /> I hereby certify that I have prepared this application.and that-the-work_will_be'done-rn_accoraance with'S n Joaquin county ordinances, state laws,ane <br /> rules and regulations of the San Joaquin Local Health'DI'ktricr _ <br /> Home owner or licensed agent's signature ceitifies the followin � �'- d i <br /> employ an g l certify fhatih ifie performance of the work.for which this permit is issued, i shall not 1 <br /> p Y y person in such manner as to become subject to workman's compensation laws of California`-",Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued shelf em to <br /> tion laws of California." p y persons subject to workman's compensa <br /> The applicant mu call for all <br /> quired inspections. Complete drawing on reverse side. r <br /> Signed X i <br /> Data: <br /> I <br /> FOR Df PARTMENT USE ONLY <br /> Ap lication Accepted by <br /> d � �` <br /> it r Grout inspection by r��/ DateArea <br /> ate .Final Inspection,b <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> Manteca 823-7104 ❑ Tracy <br /> !Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Haze835-&385lton,Ave., P.O. Box 2009, Stk., CA,,95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ~ <br /> CASH t RECEIVED aY DATE ? <br /> V.1/A 5) * PERMIT'NO, Sa <br /> } <br />