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" !I <br /> APPLICATION FOR PERMIT <br /> SAN JOAO•UIN LOCAL°HEALTH DISTRICT <br /> 1601 E. HAZE; AVE., STOCKTON, CA <br /> --Telephone (209) 466"6781 . , <br /> PERMIT EXPIRES 'f YEAR-FROM DATE ISSUED`' i <br /> (Complete in Th0caie) f <br /> application is I <br /> r <br /> ' ance No.549 for sewage or No. 1562 for,we111pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. s app <br /> pp )lance with San Joaquin County Ord <br /> made in comp titan C lq i i rJ <br /> Local Health District. I� l <br /> r, •` f f Lot Size <br /> Job Address fT f Phone' <br /> Address <br /> Owner's Name, I Phone 7 <br /> ! (J License No <br /> Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> WELL/ P NEW WELL ❑ REPAIR ❑ OTHER 5 <br /> TYPE <br /> OF W TEM R <br /> PUMP INSTALLATION SY DISPOSAL FLO. PROP. LINE <br /> II '' SEWER LINES PITS/SUMPS <br /> i DISTANCE TO NEAREST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL— <br /> u FOUNDATION <br /> s ITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Wel! Casing- <br /> INTENDED USE p <br /> i ❑ Qpen Bottom ❑ Man~ t �` Dia. of Well Excavation Specifications <br /> ❑ Industrial "Type of Casing <br /> �?DomesticlPrivate� ❑ Gravel ❑ Tracy Pack Type of Grout y _ <br /> ❑ Other ❑ Delta Depth of Grout Seal C- <br /> ❑ Public " Eastern Surface Sea! Installed by <br /> ❑ Irrigation !� �Approx...Dept � h ! State Work Done <br /> � � H.P. s <br /> k Repair Work Dane"� Type of Pump Seating'Material'{top c,0'} •- , 4 <br /> Well Destruction iF F] Wel! Diameter Filler Material (Below 50'}~ <br /> i; <br /> available within 200 feet.! <br /> p TYPE OF SEPTIC WORK: NEW INSTALLATION ID available❑ DESTRUCTION'Ll septic system rmittedif public se <br /> petliwer <br /> Depth is <br /> li Commercial Other <br /> installation will serve: Residence <br /> 11 <br /> Number of living;units: <br /> ' Number of bedrooms Water table depth <br /> Character of soil-to a depth of 3 feet: } Capacity� No, Compartments <br /> SEPTIC TANK 11 ❑ Type IMfg a Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line_r- <br /> 1 Distance to nearest: Well <br /> I � <br /> �1 <br /> 3 Total length/size <br /> ❑ No. & Length of lines <br /> Weill <br /> LEACHING LINE Ilr property Line <br /> FILTER BED El distance to nearest: ��—� <br /> Foundation_�� <br /> k i <br /> Size � Number <br /> SEEPAGE PITS 'II ❑ Depth Property Line <br /> SUMPS Ii <br /> LI Distance to nearest: Well K i Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that L have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> k rules and regulations of the San Joaquin Local Health District. I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner Or licensed agent's signature certifies the following: " of <br /> signal e <br /> employ any person in such manner as theec rfO macsubject the workman's <br /> k manor which th�ompenis perm t is ssuedifl shall employ persons rsubject t ring or bworkman'seompensa- <br /> certifies the following:"I certify that in Pe <br /> tion laws of CalifIi ornia." <br /> {' The applicant m. call for all required inspections. Complete drawing on reverse side. <br /> pate: <br /> Title: <br /> d/ <br /> _ <br /> Signed 7 <br /> FOR DEP RTMENT USE ONLY M� -4; <br /> Date f Area q <br /> Application Accepted by �` � <br /> ate <br /> it Date Final inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: ❑ Manteca 823�1p4 ❑ Tracy 8`� Stk., CA 95201 <br /> ❑ Stk 466-6751 ❑ Lodi 369-3621 <br /> Applicant- Return all copies to: Envi;•anmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. <br /> CK RECEIVED,BY ,. DATE PERMIT"NO. � <br /> 9`FEE 'AMOUNT DUE AMOUNT REMITTED CASH <br /> 1INFO- all <br /> +EH 1324(REV.1/B 51 I - <br /> EH 14-26 <br />