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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE.;.STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ..,• j. ;_ �w_ " } e" r <br /> � .. <br /> (Complete in:Triplicate) , <br /> ;cribed.This/or install the work <br /> Application is hereby made to the San <br /> Joaquin Local County Ordinance lth District for a for sewage mitor to 1862 for welcation is <br /> U pump and thconstruct e Rules and hereinR Regulations of he Sant Joaquin <br /> made in compliance with San Joaquinry w <br /> Local Health District. r :Y <br /> Job Address <br /> "iY-' City .._ Lot Size Cly , �M - <br /> ` �� Address Phone <br /> Owner's Name i� <br /> si <br /> L,�� L Address 0 License No. Phone <br /> --�� <br /> Contractor WELL REPLACEMENT 11DESTRUCTION L1 <br /> TYPE OF'WELL/PUMP: NEW'WELL9❑ OTHER 1-1PUMP-INSTALLATION-IE' �^-" " "'""SYSTEM REPAIR ❑ <br /> SEWER LINES i DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO'NEAREST: SEPTIC TANK.'S -AGRICULTURE-WEL'L <br /> OTHER WELL PITS/SUMPS <br /> .FOUNDATION - - <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i „ <br /> IN USE —_�—'— Dia:of Wel! Casing <br /> ❑ lndustriai:� «' C] Open Bottom d Manteca_- , Dia. of Well.-Excavation -� -Specifications LJ <br /> Z° ❑ Tracy Type of_Casing <br /> Domestic/•Private Tracy Pack ,, _ �. n 7"_i�#�JJ Type of Grout r <br /> ` Depth of GTOUt,56al <br /> ❑ Public ❑ Other `w .. ❑ Delta p <br /> J4pprox. Depth *.❑ Eastern Surface'Sesl Installed by J. <br /> ❑ irrigation -------- <br /> H.P. <br /> I �'State Work Done <br /> Repair Work Done ❑ Type of Pump Sea`Iing-Material (top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> r Depth Filler Material 50'1 <br /> SLR AIflIADDITIDN ❑ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION DESTRUCTION ❑ availablle,�in200feettted if public sewer is <br /> i " a <br /> Installation will serve: Residence LJCommercial her <br /> Number of living units: Number of bedrooms Water'table depth <br /> Character of soil to a depth of 3 feet: C Capacity No. Compartmen-est <br /> SEPTIC TANK Q/TYpe/Mfg r Method of Disposal,, <br /> PKG. TREATMENT PLT. ❑ r i s <br /> r i Foundation roperty Line <br /> Distance to nearest: Well <br /> Total I gthlsize <br /> LEACHING LINE C4�No• & Length of lines <br /> 1 1 <br /> n i-► Foundation -- Property Line <br /> FILTER BED` Cl Distance to nearest: Well-7[L__- <br /> 3� <br /> "$ Size Numb r <br /> 1a� <br /> SEEPAGE PITS tspth yProperty Line <br /> j .0 . Distance-to-nearest: _Well - 'dation { <br /> SUMPS , <br /> ` DISPOSAL PONDS ❑ r <br /> 1 hereby certify that V have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> shall not <br /> rules and regulations of the San Joaquin Local Health District.g work for <br /> Home owner or licensed agent's anne9as torbecome subj c�lto workman's <br /> rtcompensation lawsoof California." ContraCtors'h hiring OP5 b COlItIaCt f1germit is issued, I5 gl18tiJ e <br /> employ any person in such p y persons subject to workman's COmpensa- <br /> certifies'the following:"l certify that in the performance of the work for which this permit is issued, 1 shall em to R r <br /> tion I w f California." ~ <br /> The applican us call or 1! re ired ins tions o eta drawing an re ar11 <br /> se side t <br /> Title: Date:,-3 c�3r 8Y- <br /> • , <br /> �r Signed Y a ,. ; FOR DEPARTMENT USE.ONLY <br /> } i . Date h Area 0 <br /> lication Accepted by !! - _ � T _ � _ZS <br /> - --� <br /> Final inspection by bate <br /> c--Pii Grout Inspecti oby <br /> C+�r Date V A <br /> Additional Comments: <br /> ❑ Stk 466-6781. <br /> ❑ Lodi 369-3621 ❑ Manteca 823-7104 1. ❑Tracy 83x6385 <br /> Annlicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA t <br />