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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 1 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> No.549 for sewage or No.1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local <br /> Health District for a permit to construct and/or install the work herein described.This <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. Q� PM <br /> City ooWT�- Lot Size <br /> Job Address 5 #4.j,-77 Phone <br /> vS'�s <br /> .. PD g /e Address <br /> Owner's Name <br /> License No Phone <br /> Contractor Address DESTRUCTION ❑ <br /> NEW WELL RE AGEMENT <br /> WELL L1 ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LINES PITS/SUM`I* -- <br /> DISTANCE TO NEAREST: SEPTIC TANK ----- AGRICULTURE WELL OTHER WELL_-- <br /> FOUNDATION ----- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Industrial ❑ Tracy Type of Casing <br /> ❑ Gravel Pack Type of Grout <br /> ❑ Domestic/Private ❑ Delta Depth of Grout Seal <br /> ❑ Public ❑ Other f" <br /> _�o,pprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation H P State Work Done <br /> VJ <br /> Repair Work Done ❑ Type of Pump — Sealing Material (top 501 05 <br /> Well Destruction ❑ Well Diameter _----- Filler Material (Below 50') W <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTIOUJ <br /> N ❑ INo septic system permitted if public sewer 1 <br /> Installation will serye: Residence; Commercial_ Other V1 <br /> �1 Number of bedroortls Water table depth <br /> Number of living units: � <br /> Character of soil to a depth of 3 feet: Capacity____-- No. Compartments <br /> SEPTIC TANK [I Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ` Foundation -- Property Line <br /> Distance to nearest: Well <br /> Total length/s¢e <br /> LEACHING LINE No. &Length of lines Fdation *47-17 Property Line �—=— <br /> FILTER BED l <br /> ❑ Distance to nearest: Well <br /> Size Number <br /> SEEPAGE PITS ❑ Depth F_ Property Line------ <br /> SUMPS C] Distance to nearest: Well <br /> Foundation---- <br /> DISPOSAL PONDS ❑ <br /> erti .that 1 have prepared this application and that the work will be.111 doIll ne in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby c fY <br /> rules and regulations of the San Joaquin Local Health District g. <br /> workman's compensation laws of California." Contractor's shin subject to workman's sub-contrature <br /> acting <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 /> comp <br /> employ any person in such manner as to'become subject to <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons <br /> tion laws of California." <br /> The applicant must call for all quire ' tions. Complete drawing on reverse side. <br /> nspecDate: <br /> Titled" <br /> Signed <br /> FOR DEPARTMENT USE ONLY r <br /> Date J Area e---- <br /> Application Accepted by Date <br /> 6:!�Pit or Grout Inspection by <br /> Date------ Final Inspection by <br /> Additional Comments: ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 <br /> ❑ Stk 466-6781 <br /> tal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> Applicant- Return all copies to: EnvironmenStk., CA 952 <br /> CKRECEIVED BY DATE PERMITNO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH' <br /> INFO <br /> +EH 13-24(REV.1/e 5) S c� <br /> EH 14-26 <br />