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1W <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) is <br /> ll the work <br /> rein <br /> s application <br /> Application is hereby made n theJoaquin <br /> San Joaquin Local Health uin County ordinance No.District549 for sewage or permit <br /> No. 1862 for well//pump and he Rules and Regulations offtthe San Joaquin <br /> made in compliance with San q <br /> Local Health District. City Lot Siz <br /> � - X c{O PM <br /> tk__AQ,, <br /> Job Address � I Phone <br /> Address 7s-1U -Owner's Namei`d S <br /> Q License NoZo z� Phon <br /> Contract Address + Q <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUGTION EJ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR El PROP. <br /> ❑ <br /> PUMP INSTALLATION 12 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> ED Domestic/Private ❑ Gravel Pack ❑ Tracy Type of firing <br /> ❑ Public F1 other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _� pprox. Depth ❑ Eastern Surface Seal installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IO <br /> REPAIWADDITN ❑ DESTRUCTION Ll (No <br /> septic tsy hm 200 feettted if public sewer is <br /> Installation will serve: Residence P--' Commercial_ Other / <br /> Number of living units:__L_ Number of a rooms Water table depth <br /> Character of soil-to a depth of 3 feet: , Ca6_ No. Compartments <br /> SEPTIC TANK gr Typomfg pacity g _— <br /> _ { f Method of+IDisp95al � <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation— D <br /> No. & Len Length of lines Total lengthlsize <br /> LEACHING LINE g Foundation Property Line— <br /> FILTER BED ❑ Distance to nearest: WellQI �d <br /> d Depth Size Number <br /> SEEPAGE PITS ��� Property Line <br /> SUMPS [I Distance to nearest: Well�� Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 car*that in the performance of the work for which this permit is issued <br /> , I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the fallowing: u certify that i fie,.pertormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t tali for all r q 'red spections. Complete drawing on reverse si7.VQ <br /> Title: — Date: (} <br /> Signed <br /> r FOR DEPARTMENT USE ONLY <br /> Date Area ` <br /> Application Accepted by <br /> final Inspection by Date <br /> Pit or Grout Inspection by Date 4)ii 'o <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 LD Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NM <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO c <br /> 7 <br /> �� YlD � 'so <br /> + EH 1344IREV.1/65 I —713.00 1"�yl <br /> EH 1436 <br />