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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209}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 <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ and the Rules and Regulations of the <br /> 1 Local Health District:'• y. nbed. This application is <br /> 'rE,;tis San Joaquin <br />} Address N <br /> Joh <br /> 3 Add ` p <br /> 1 a City Lot Size PM <br /> Owner's Name <br /> E Address <br /> f e, Phone <br /> Contractor L -� Address Lk CC-) <br /> TYPE OF WELL/PUMP: -NT License No.1547 <br /> NEIN WELL ❑ WELL REPLACEMENT ❑ Phone G7 <br /> PUMP INSTALLATION ❑ DESTRUCTION C <br /> DISTANCE TO NEAREST: SEPTIC TANK . SYSTEM REPAIR Q OTHER ❑ I <br /> —� SEWER LINES � DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL <br /> TYPE OF W — PITS/SUMPS <br /> ❑ Industrial _ <br /> WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ~� <br /> ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel PackDia. of Well CaPublic ❑ Tracy sing <br /> IDType of Casing <br /> ❑ Other Del Depth of Grout Seal Specifications <br /> EJ Irrigation <br /> — Type of GroutApprox. Depth ❑ Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction r–~ H'P' State W rk Done <br /> ❑ Well DiameteSealing Material (top 50') j <br /> Depth <br /> TYPE Filler Material (Below 501) <br /> OF SEPTfC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES7RUCTfON ❑ ;No septic system <br /> _ Permitted if public sewer is <br /> Installation will serve: Residence <br /> Commercial_ available within 200 feet.) <br /> Number of livin units: Other <br /> g Number of bedrooms <br /> Character,of,soil.to,a-depth-of,3-feet: <br /> c-:� <br /> SEPTIC TANK ❑ Type/Mfg 4_. <br /> Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity f <br /> { No. Compartments <br /> Distance to nearest: WellMethod of Disposai <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines �d <br /> FILTER BEIS ❑ Distance to nearest: WellTotal length/size <br /> j Foundation Property Line " <br /> SEEPAGE PITS ❑ Depth ( i <br /> SUMPS Size Number `�- <br /> 1j ❑ Distance to nearest; Well <br /> DISPOSAL PONDS ❑ Foundation property Line ! <br /> k <br /> I hereby certify that! have prepared this application and that the work will be done in•accordance with San Joaquin coup ------ <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the foflowin county state laws, and <br /> employan g "I certify that in the performance of the work for which this �'" <br /> Y Person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the�foAowin permit is,ssued, I shall not <br /> g: "I certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of California." p y persons subject to wortc'man's com <br /> The applicant Pensa- <br /> or all`!`-ired"!nctrons�Camp)ete drawing on revs side. <br /> t .rtr <br /> Signed77/7 r I <br /> Title: L1 i <br /> � Date:SCJ 3 <br /> s FOR DEPARTMENT USE�ONLY <br /> Application Accepts y <br /> Date Area d <br /> Pit or Grout Inspection by f <br /> Additional Comments: <br /> Date Final Inspection by <br /> _ � Date �/ r <br /> ❑ Stk 466-6781 . <br /> Lodi 369-3623 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return alt copies to: Environmental ea ervtces 1 <br /> Wl IE. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED RECEIVED BY <br /> o� 5 DATE PERMIT''NO. <br /> + EH 13-24 iREV.t/BS) (� <br /> EH 14-28 <br />