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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instalk the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 PM <br /> r— AO City a Q Lot Size <br /> Job Address <br /> y� SuJ e,2 e Address Phone O w <br /> Owner's Name ! <br /> Contras <br /> t L4 Add ss License No...- �—Phone ? <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT LJDESTRUCTION <br /> ❑ <br /> PUMP INSTALLATION C>�' <br /> SYSTEM REPAIR OPo' OTHER ❑ <br /> ' SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITSISUMPS <br /> TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS <br /> INTENDED'USE Dia. of Well Casing <br /> ❑ <br /> Dia. of Well Excavation <br /> Industrial ❑ Open Bottom (71 Manteca Specifications <br /> ? Type of Casing <br /> �omesticJPrivate ❑ Gravel Pack ❑ Tracy Type of Grout <br /> Public <br /> ` ❑ Other F1 Delta Depth of Grout Seal <br /> I`l <br /> E I Irrigation —ApproxDepth i I Eastern Surface Seal Installed by <br /> Repair Work Done <br /> 19ii� Type of Pump. H.P. State Work Done — <br /> ' ff <br /> _ Well Destruction ❑ Welt Diameter Sealing Material itop 501 �} <br /> Depth s Filler Material (Below 501 <br /> - <br /> TYPE O SEPTIC WORK: NEW 1NS�ALLATION i 1 REPAIR/ADDITION l 1 DESTRUCTION I I (NailabPeset1c system 1pe witfiin 200 feetitted it public sewer is r n <br /> Installation will serve: Residence k Commercial f Other <br /> " Number of living units: Number of bedrooms L- <br /> ;!rl <br /> depth <br /> Character of soil to a depth of 3 feet: ments <br /> SEPTIC TANK ❑ Type/Mfg Capacity -isposal �PKG. TR�ATMENT PLT. ❑ Prto nearest: Welt FoundationrTotal lengLEACHING INEC No. & Length of linesPFILTER BED ❑ Distance to nearest: WeFoundation <br /> I Depth ,—Size Number <br /> SEEPAGE PITS + Property Line <br /> SUMPS <br /> L-1Distanceto nearest: Well Foundational ` <br /> DISPOSAL PONDS _ - ❑ e laws, and <br /> e I hereby certify that I have prepared this application and that the work willbedone in accordance with San Joaquin county ordinances, stat <br /> rules and regulations of the San Joaquin Local Health Di'ktrict. <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 signature <br /> shall not. <br /> employ any parson in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring <br /> sub est t workman's-contracting <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, Y shall employ p 1 <br /> I' tion laws of California. t <br /> The applican ust call for all quire inspections. Complete drawing on reverse side. <br /> Data: <br /> Signed X <br /> l OR�EPAR�TMENT USE ONLY s�� <br /> Date Area <br /> Application Accepted by <br /> Dat <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, 5tk., CA 95201 <br /> s Fr <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> " INFO ��11 �ta/l� �Q/J <br /> ..EH13-24(REV.I/Kb1 �S'< o V 3�' L> 23� `���� <br /> EH 14-26 <br />