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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601-E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> m <br /> .made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pup and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 60 Il City Lot Size PM <br /> I Job Address <br /> Owner's Name �A Address <br /> �J 6 a 44 /` '+ Phone ¢ �� <br /> Contractor Address <br /> pjsl License No. .PJ 7,11 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONR Cly+ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR � � q <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP' LINE \ <br /> j. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> INTENDED USE . TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 9 <br /> Dia. of Well Casing <br /> ❑ Industrial 1 ❑ Open Bottom ❑ Manteca Dia- of Weil Excavation 1 <br /> ❑ Domestic/Private ❑ Gravel Pack Q Tracy Type of Casing <br /> Specifications a, <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> F7 Public _ <br /> i I Irrigation Approx. Depth l-.I Eastern Surface Seal Installed by <br /> H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Ma <br /> Material Stop 50'1 <br /> k Well Destruction ❑� Well Diameter <br /> - Depth Filler Material (Below 50') <br /> TYPE{OF SEPTIC WORK:. NEW INSTALLATION I'i REPAIR/ADDITION DESTRUCTION I i available w tMo septic hin 200 fesm retl`')ed if public sewer is <br /> Inst llaf in wilt=ese ve Re dance Commercial Other <br /> �Numbe of living units: Number of edroom� Q { <br /> Character of soil to a.depth of 3'feet: 111 d�1 ti _Water table depth <br /> t Capacity No. Compartments <br /> SEPTIC TANK �] Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> I i <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE C_4-'_No. & Length of lines Total length/size <br /> FILTER BED LlDistance to nearest: Wtell �- . Foundation Property Line <br /> SEEPAGE PITS I I Depth Size r*' Number <br /> ' <br /> SUMPS D Distance to nearest: Well Fou n ati n Property Line <br /> 17 <br /> j%I) POSAL PONDS ❑ "_� <br /> 1 ; `1.f 4 s <br /> 13 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 /> t rules and.regulations of,the San Joaquin Local Health Di?;trict. <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this Wrinit is issued, I shall not <br /> employ any person in such manner as to become subject to work+nan's-compensation'laws-of-CalifcrRnia." Contractor's hiring or sub-contracting signature <br /> certifies the following- '0 certify-that-in the-perform rice of the work for which this permit is issued, f shall employ persons subjer to workman's compensa <br /> tion laws of California.' > <br /> The applicant ust call!for of`squired inspect ons; Col to dowing on re erseas d <br /> t Title: ' Date: r <br /> t Signed X 1 ]]7 <br /> i FOR DEPARTMENT USE ONLY (� <br /> Date Ar ea <br /> Application Accepted II p <br /> ur Date 7 4 <br /> Pit or Grout Inspection�by Data Final Inspection by 1 <br /> Additional Comments; <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 (_0 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health PermiiLSecvices 1601 E-Hazelton Ave:, P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEECK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> AMOUNT DUE ;A;MOUNT REMITTED AASS`H <br /> +.EH 13-24{REV.11951 74)-66 '�� <br /> EH 1426 <br />