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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I I� (Complete in Triplicate) <br /> Application is hereby madel�to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This a licati <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of he San Joaquin <br /> Local Health District. ` Pf> nn is <br /> Job Address <br /> ii City <br /> Lot Size PM <br /> Owner's Name II r ff <br /> A <br /> Phone <br /> F Contractor <br /> I Address _ e)4 <br /> TYPE OF WE /PUMP: I NEW WELL _JU se No. Phonf <br /> F >UMP INSTALLATION [ WELL REPLACEMENT ❑ DESTRUCTION LI <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> l SEWER LINES ._�� DISPOSAL FLD. <br /> FOUNDAT[ON PROP. LINE <br /> AGRICULTURE WELL <br /> [INTENDED USE OTHER WELL PITS/SUMPS <br /> I�TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl In�strial (I Open Bottom �—nt—� —e <br /> Q Manteca Dia. of Wll E=xcavation <br /> Domestic/Private �� Gravel Pack Dia. of Well Casing <br /> 'I <br /> FI Public ' ' i racy Type of Casing <br /> Irrigation <br /> f� Other � Delta Depth of Grout Seal Specifications <br /> f 'I i� <br /> Approx. Type of Grout <br /> ,. prox. Depth I 1y,Eastern S )ace Seal Installed by <br /> Repair Work Done [J Type of Pump •, <br /> H.P. <br /> �l <br /> Well Destruction Q Well Diameter State Work Done <br /> Seating Material atop 50'1 <br /> Depth Filler Material ;Below 50'1 <br /> TYPE OF SEPTIC WORK: fV`6EW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted i! public Sewer is <br /> Installation will serve: Residence available within 200 feet.! <br /> Commercial, Other <br /> Number of living units: 9M Number of bedrooms <br /> Character of soil to a depth�of 3 feet: <br /> SEPTIC TANK ❑ I`Type/Mfg WaieL <br /> PKG, TREATMENT PLT, ❑ E Cap <br /> acity-� <br /> I �a is <br /> Distance to nearest: Well GENEM P <br /> IM Foundation <br /> LEACHING LINEI IHT <br /> & Length of lines gQIJ <br /> FILTER BED i Total ler <br /> ❑ M istance to nearest: Well - <br /> Foundation_ _ r, <br /> SEEPAGE PITS it Depth ENNA <br /> i <br /> SUMPS Size --� Number <br /> Ll Distance to nearest: Well � <br /> DISPOSAL PONDS rI 1. Foundation Property Line <br /> 1 her certify that f have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state 1 <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: laws, and <br /> employ any person in such manner as to become subject to workman's compensation i tion laws of California."Contractor's Kirin <br /> "f certify that in the performance of the work for which this permit is issued, l shall not <br /> certifies the following: "I Certify hat in the performance of the work for which this permit is issued, I shall C to <br /> tion laws of California." I g or sub-contracting signature <br /> employ persons subject to workman's compenun J` <br /> The applicant must cap for ail required inspections. Complete drawing on reverse side. 1 <br /> Signed X G I� <br /> Title: _ k <br /> Date: — <br /> i <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date <br /> _ ,rte )r <br /> Pit or Grout inspection by IN Area <br /> II Date-� Final Inspection by �,,} <br /> Additional Comments: �p' Date G�-2- <br /> 0 Stk 466-6781 ❑ Lodi'.,*9-3621 <br /> Applicant - Return all copies to: Environmental Health haPermit/nieca 5erycess 1601 EHazelton 3-7104 Tracy 3Ave., PA Box 2009, Sik., CA 95201 <br /> FEE AMO <br /> INFO UNT;bUE <br /> AMOUNT REMITTED <br /> H R CEIVEO BY p TE <br /> EH 13.24(REv.1/q5) q �' PERMIT'NO. <br /> EH 14-26 <br /> i <br />