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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 >r. HAZE T ON AV>r.; STOCKTON, CA <br /> Telephone 1209) 46Ei'6781. " <br /> PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED <br /> (Complete in Triplicate) This application is <br /> permit to construct and/or install the work herein descLbed•ons of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a pe <br /> and the Rules and Reg <br /> made in compliance with San Joaquin County Ordinance No;549 for sewage or No.1862 for well/pump ( <br /> Local Health District. r,. f ,, PM <br /> r `rr, City �'"�•` Lot Size C <br /> I +�0� <br /> Job Address – -- �� - Phone�� T <br /> Address <br /> 1 Owner's Name O Phone <br /> G j, pc ?_4 icense No. L — <br /> Address O DESTRUCTION L3 { <br /> Contractor lztNEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ \ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PROP, LINE �] <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. <br /> SEWER LINES —� OTHER WELL— PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK � AGRICULTURE WELL <br /> FOUNDATION �� <br /> TYPE OF WELL PROBL_ EM AREA CONSTRUCTION SPECIFICATIONS Dia.*of Well Casing <br /> INTENDED USE CI " Dia. of Well Excavation Specifications " <br /> L] Industrial a p-Open Bottom Type of Casing <br /> ❑ Gravel Pack C3 Tracy Type of Grout <br /> ❑ Domestic/Private" - [T Delta Depth of Grout Seal <br /> ❑ Public 4 ❑ Other Surface Seal Installed by r <br /> L3 Irrigation I �pprox. Depth C1 Eastern H.P.Type of Pump State Work Done <br /> Repair Work Done ❑ Sealing Material /top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth em rmitted if public sewer is <br /> available within 200 feet./ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nos syst pe <br /> ✓ ,_�-- " <br /> Installation will serve: Residence Commercial— Other � �Q <br /> r Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: I No. Compartments L <br /> �1 ype/Mfg Capacity <br /> SEPTIC TANK – Method of Disposal <br /> 1 <br /> PKG. TREATMENT PLT. 11Distance <br /> Property Line <br /> `ti pistance to nearest: Well O i <br /> ' <br /> Total length/size <br /> LEACHING LINE r p"'No. & Length of lines r Foundation © Property Line <br /> ❑ Distance to nearest: Well <br /> FILTER SED <br /> i Size _Number <br /> SEEPAGE PITS ❑ Depth - �` Property Line <br /> - Foundation <br /> SUMPS ❑ Distance to nearest: Well 5 <br /> l T <br /> i <br /> aws, an <br /> DISPOSAL PONDS ' ❑ <br /> d this application and that the work will be done in accordance with San Joaquin county ordinances, state <br /> I hereby certify that 1 have prepare <br /> � n <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies <br /> subject Ito workman'srtcompensatiori'lam of Californ a." Contractor's or sub-contracting signature <br /> employ any person in such manner as to bac <br /> arsons subject to workman's compensa- <br /> certifies the following:."I certify that in the performance of the work for which this rmit is issued,I shall employ p <br /> tion laws of California." r 11 <br /> The applicant must call f r all squired 'inspection. Complete•drawing on-reverse side <br /> £ alk 4 Date: 7' <br /> Title:_ <br /> Signed <br /> FOR DEPARTMENT USE ONLY y <br /> ' Date Area <br /> Application Accepted by ' E Date ` ' <br /> ( <br /> Date Final'Inspection by <br /> Pit or Grout Inspection by <br /> �� - <br /> Additional Comments: -� p IVlanteoa."823 7104 ❑ Tracy�`835-6 Stk., CA 95201 <br /> D Stk 466-6781 —❑'L".odi 369-3621. <br /> Applicant Return all copies to: Environmental Health permit/Services tS01 E'1Hazelton Ave., P.O. Box 2009. <br /> CK DATE PERMIT'NO. <br /> FEE AMOUNT REMITTED CASH RECEIVED F3Y } <br /> AMOUNT DUE <br /> INFO Cr <br /> +EH 13-24 4REV.1/6 51 <br /> EH 14-28 _ -.. <br />