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a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> l } Telephone (209) 466-6781 <br /> Ems' PERMIT EXPIRES 11,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) and/or install the work # <br /> . This <br /> .. - cation is <br /> : " ,<. <br /> Application is hereby"made to the San JooaqurnOLocal <br /> d nalHealth District for a nce No.549 for sewage o permit <br /> No. 1862 forcwoupump and the Rules and IR Regulations of he Sanr Joaquin <br /> made-in compliance withFSan Joaquin County <br /> Local Health District. ^ <br /> 1 > PM <br /> i Cit of Size <br /> Job Address' <br /> Phone u <br /> Owner's Name ` Address 1 <br /> 17 <br /> Contractor <br /> d.dress t- license No. Phone <br /> TYPE OF WEL 1 U P: It ELL ❑ WE L REPLACEMENT C] DESTRUCTION ❑ l <br /> OTHER 0 <br /> PUMP IN aLLATION SYSTEM REPAIR Elt DISPOSAL FLD. PROP. (_INE <br /> DISTANCE TO NEAREST: SEPTI -TANK SEWER LINES <br /> FOU DATION AGRICULTURE WELL OTHER WELL- PITS/SUMPS <br /> INTENDED USE °'TYflE OF WE t'l~` <br /> PROBLEM ARE' CONSTRUCTION SPECIFICATIONS <br /> µy pia. of Well Casing <br /> ❑ liidustriai ` Open Bottom 0 Manteca Dia. of Well Excavation <br /> ^ "°"" - `* Type of Casing Specifications — <br /> 1 ❑ DomsTic7Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> 100 ❑F] Public— Other Cl Delta Depth of Grout Seal <br /> I I Irrigation -Approx. Depth l-] Easiem" Surface'Seallnstalled'by-� <br /> Repair Work Done ❑`' Type of Pump H.P. <br /> Stat Work Done <br /> ! Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION DESTRUCTION { I s(No <br /> septic hinem rented if public sewer is <br /> avar' kw <br /> Installation will serve: Residence Commercial— Other # <br /> t <br /> Number of living units: Number of bedrooms { Water table depth <br /> Character of soil to a depth of 3 feet: ,, <br /> SEPTIC TANK ❑ Type/Mfg IL I <br /> Capacity No. Compartments <br />{(i PKG. TREATMENT PLT. Elr r Method of Disposal <br /> I Distance to nearest: Well Foundation a. Property Line <br /> j ..� .„ —� Total length/size <br /> LEACHING LINE LI No.'& Lingth of lines <br /> FILTER BED ❑ Distant to nearest: Well Foundation Property Line <br /> SEEPAGEPITSI Depth Size Number u <br /> L-1 Distance to nearest: Well Foundation Property Line,_- <br /> SUMPS, f , <br /> DISPOSAL PONDS ❑ I t <br /> .1hereby certify that n cordance with San Joaquin county ordinances, <br /> I have prepared this application and that the work will be done.i <br /> state laws, and <br /> "rules and regulations of,the San Joaquin Local Health District. <br /> owner or licensed agent's signature certifies the'foilowing: "I cert ify,that-in a performance of the work for which thio sub-contracting Isgnaturre <br /> not <br /> Home ow f3 <br /> employ any person in such manner as to become subject to workr�f6n<s compeTSsatlon laws of California." Contractor's hiring <br /> 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 /> tion laws of California." . �'` . r <br /> The applicant m t f II requi i pections_ Complet drawing on ers side. <br /> rrig <br /> Signed X Title: ; Date: <br /> FOR DEPART USE ONLY <br /> Date r Area <br /> f APP' . ccepted by <br /> Final Inspection Date <br /> j - it or Grout Inspection by pate <br /> t r ,✓' x <br /> Additional Comments: <br /> I Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-7104 15-Tracy 835-6385 <br /> .Appoant- Return all copies to: Environmental Health Permit/Services 115011E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> :�-+ CIC RECEIVED 8Y <br /> .1 FEE DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ' r EH 1324 IREV,i H 57 r �� <br /> EH 14-26 - <br />