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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 .- u <br /> PERMIT EXPIRES 1 YEAR FROM'DATE ISSUED <br /> �� r ;.. •4- ;: ,� Y„a {Complete in T(plicate) <br /> iti/or install the work <br /> .This <br /> Application is hereby made to the San Joe Corin n is <br /> U1Ordinance lNo.District Health 549 for sewage or permit <br /> 1862 for cwell/dpump and the Rules and IRegu�lationnss of the San Joago u n <br /> r, made in compliance with San JoaquinN <br /> Local Health District. <br /> Q _ City , Lot Size_ PM <br /> Job Address V _ <br /> 1C.P1111 �/ T/w�LAddress T Phone <br /> Owner's Name <br /> t ` PhoneZ <br /> S Address_ . License No. <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL L; WELL REPLACEMENT ❑ <br /> fEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION �fa�Mt,��� DISPOSAL FLD. PROP. LINE <br /> \A� EWER LINES �� <br /> DISTANCE TO NEAREST: SEPTIC TANK � � OTHER WELL PITS7SUMPS <br /> FOUNDATION AGRICULTURE WELL - _-• <br /> _v rte:,, i.off. �_._.,�- -- <br /> ""` 11VTENDEp USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> 17Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ; <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> Ll Public ❑ Other <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surf ce Seal Installed by l <br /> H P State Work Done f <br /> Repair Work Done ❑ Type of PumpJ$ <br /> k Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material {Below 5o') <br /> I <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑• DESTRUCTION ❑ aNailablelwthm Z00 feetiled if pub lc sewer is <br /> Installation will serve: Residence— Commercial— Other -- <br />' Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK fl Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well �! <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines I ►� 4 Property Line <br /> FILTER BED [I Distance to nearest: Well k` o) 2, r)dation - <br /> Number <br /> SEEPAGE PITS ❑ Depth Size <br /> Property Line <br /> {-" ` <br /> t SUMPS ❑ Distance to nearest: Well Foundation j <br /> DISPOSAL PONDS El. ' <br /> I hereby certify that I have prepared this application and that the work will be.dor in accord_anccewith San Joaquin county ordinates, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. _ ,_____c.e a �-- r <br /> Home owner or licensed agent's signature certifies the fallowing: "I certifyithe in the performance of the work#or which this permit is issued, k signashall ture <br /> ring or sub <br /> employ any <br /> following:in:such <br /> e manner that n the corn mancsubject to workmainj he wok for vuh ch this perm'rttion vis issued,I shall emploof California" y parrsonsrsubj subject to workmant'sc mpensa- <br /> certifies t 9 ' <br /> I tion laws of California." <br /> i The applicant c SII quired i t' ns. Complete dyawing on rev rse�. <br /> Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT SE ONLY / <br /> Date C�— �I� Area <br /> Application Accepted by /J <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date`�- ^T -� <br /> Additional Comments: <br /> ❑ <br /> Additional <br /> 46Com ❑Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy" 8355-6385 <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 TE M <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO � EE <br /> +EH 13.24(REV. <br /> EH 14-29 ... _.. <br />