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�l <br /> APPLICATION FOR PERMIT <br /> j SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> sewage a r t well/pump and the Rules and Regulations of the San Joaquin <br /> N 1862 far <br /> alth District <br /> made in compliance with San Joaquin Co <br /> Application is hereby made to the San Joaquin LocalNo.549 for ser ag permit to construct and/or install the work herein described. This application is <br /> pP <br /> Ii unty Ordinance <br /> j Local Health District. <br /> II' <br /> k r City Lot Size PM <br /> Job Address fI <br /> Phone <br /> F w. �i. BE16.' : QLi2 Address <br /> Owner's Name Iit License No Phone - <br /> Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> - PUMP INSTALLATION 550 SYSTEM REPAIR ❑ <br /> f DISPOSAL FLD. PROP. LINE . <br /> SEWER LINES �--- — pITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK _.SEWER <br /> WELL OTHER WELL <br /> FOUINDATION T = �— <br /> y' 11NTENDED=USE-- w--TY-PE-OF;�WELL_PROBL�-ENI��AREA ONS:FRUCzaON-SP�CIFICATJONS. Dia, of Well Casing <br /> El Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Domestic/Private __ - "Type of Grout <br /> rte❑ OtiFi�" ❑ Delta ""Depth of Gflodt-Seat T" -` ' A <br /> F1 Public ,. . _ �_ 1 „^ ate. <br /> 1 1 Irrigation Approx Depth a'1 Eastern.: + Surface Seal Installed by <br /> H-P- State Work Done <br /> t Type of Pump �l1-�1--- r <br /> I Repair Work Done ❑ VP Sealing Material (tap 50'1 {} <br /> } Well Destruction ❑ Well Diameter <br /> Depth ' ~# Filier.Material'(Below.50') <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIRlADDITION l k : DESTRUCTION l 1 (No septic system permitted if public sewer is 6 <br /> Commercial. Other ti �tiIr <br /> Installation will serye: Residence fes'`— ��;, 1tt 'a <br /> Number of living units: Number of bedrooms Water <br /> Character of soil to a depth Iof.3 Meet: Capacity No. Cogtdartments <br /> SEPTIC TANK ❑ 'Type/Mfg Method of Djs� al� <br /> il. L-; M <br /> PKG. TREATMENT PLT. ❑ �i Foundation Property.Line <br /> I'Distance to nearest: Well <br /> r Total length/size <br /> LEACHING LINE 11ilND. & Length of lines Pro erty Line Ef?1'1C�� <br /> I Foundation P ' <br /> FILTER BED ❑ '�Distance to nearest: Well _ <br /> f " Size Number t <br /> SEEPAGE PITS 4 I i Depth l <br /> SUMPS ❑ � Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ li r, <br /> I 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 /> f, rules and regulations of the San'Joaquin Local Health District. <br /> Home owner or licensed age signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person it suc not as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the fol49ey the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensation laws of CThe applicant .1hali"in <br /> d inspections. Complete drawing on reverse side. <br /> Title: Date: <br /> 0/28189 <br /> Signed X <br /> �QR PARTMENT USE ONLY O <br /> Date Area <br /> Application Accepted by <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 - ❑ Lodi 36a-3621 ❑ Manteca 823-7104' ❑Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 11 f <br /> CK RECEIVED BY PATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ti `3 f31 �1 �A-b <br /> +•EH 13-24(REV.t <br /> EH 14-26 <br />