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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZETON AVE., STOCKTON, CA e <br /> Telephone 1209} 466-6781 <br /> ,PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> it (Complete in Triplicate) <br /> . This <br /> cation is <br /> t and/or install the work <br /> n descr <br /> Application <br /> Icompliance with Sano the San Joaqu n County Ordinance No.549 for sewage Or uin Local Health District.for a permit <br /> No. 1862 for weiupump and the Rules and(Regulations of the Sang Joaquin <br /> ma <br /> t <br /> Local Health district. <br /> (% t PM Lot Size <br /> b City f <br /> Job Address <br /> V 'Address Phone <br /> Owner's Name ! _C NContractoAddress 7=Rw <br /> Q is e No. <br /> r1 sL-Phone <br /> ��� <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES <br /> DISPOSAL FLD. PROP" LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> A Dia:of We11=Casing <br /> — "❑ Open Boitom�=❑ Manteca Oia. of 1NeIl E>icavation <br /> El Industrial Specifications <br /> '(Domestic/Private ❑ Gravel Pack El Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> Public n Other ❑ Delta <br /> Approx. De�h l 1 Eastern Suriaca Sea! Installed by <br /> I I Irrigation <br /> I h H.P. State Work Done <br /> Repair Work Done LJ Type of Pump+ <br /> Well Destruction LD Well Diameter, I� Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> c system permitted <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.'i REPAIR/ADDITION I ! DESTRUCTION i I alvailabl�erwithin 200 feet.) if public sewer is <br /> I�will serve: Residence Commercial— Other <br /> Installation { <br /> Number of living units: Number of bedrooms <br /> I <br /> Water table depth \1\ <br /> Character of soil to a depth of 3 feet. No. Compartments <br /> SEPTIC TANK Q Type/Mfg- Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I� <br /> _ Number <br /> SEEPAGE PITS l 1 Depth Size Property Line <br /> SUMPS Ll Distance,to nearest: Well Foundation P rtY <br /> _,_•..DISP-OSAL-',PONDS x <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> j rules and regulations of the San Joaquin Local Health District. <br /> I` 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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i 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." f <br /> I The applicant m all for all requir inspe ons. Complete drawing reverse side. /� _e^�� <br /> Title: Dale: <br /> Signed X <br /> I <br /> �?, P�ARTME�N_TTUSE ONLY <br /> �b ,q� _A_ <br /> Date_ _.�-- Area <br /> Application Accepted by <br /> I Pit or Grout Inspection by <br /> Date Final Inspection by Date Z <br /> Additional Comments: <br /> ❑ Stk 466-6781 L1 Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 835-6385 <br /> Applicant- Return all copies to: Envir-nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IL IT NO. <br /> FEE CK RECEIVED BY DATE PERM <br /> AMOUNT DUE OUNT REMITTED CASH <br /> INFO `�� '] j�/� <br /> +.EH 13-241HEV.t/95) J 10 k / 1 0 ;r�� �u~� <br /> EH 14-28 <br />