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APPLICATION FOR PERMIT -r <br /> HEALTH DISTRICT <br /> SAN JOAO.UIN LOCAL H ,� � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ` <br /> Telephone 0O) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,,. . <br /> [Complete in Triplicate? <br /> Joaquin County�OLoca H No.District <br /> for sewage r No. 1882 for we <br /> 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 and/or install the work herein described-This application 1s <br /> made in compliance with San s rt <br /> "Local Health District. r„ s.... ,. A: <br /> r a City Lot Size <br /> PM <br /> Job Address v uv:�; :�.. t • zF <br /> r �& T Phone / C <br /> A �.c a Address 46 <br /> Owner's Name v�- <br /> License No.�_��—Phone <br /> Contractor Address . <br /> El OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION fl <br /> SYSTEM REPAIR ❑ OTHER ❑PROP. LINE <br /> LINES �— D <br /> DISTANCE TO NSEWER AL FLD.EA T: SEPTIC TANK PITS/SUMPS <br /> NDATION AGRICULTURE WELL OTHER WELL <br /> TYPE 0 PROBLEM ARFA�ONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> INTENDED USE F <br /> ❑ Industrial ❑ Open Bottom nteca Dia. of Well Excavation Specifications <br /> T of Casing <br /> ❑ Domestic/Private ❑ Gravel Pae ❑ Tracy Dep rout Seal Type of Grout <br /> Q Public <br /> er ❑ Delta <br /> d Irrigation <br /> --P--Approx. Depth ❑ Eastern Surface Seal Insti3Hed by <br />{ H.P. State Work Done <br /> Repair Wo one ❑ Type of Pump �- <br /> Sealing Material [top 501 <br /> Well estruction ❑ Well Diameter Filler Material {Below 501 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/A6DITlON ❑ DESTRUCTION (No <br /> ailable�within 200 feet.) if public sewer is <br /> installation will serve: Residence— Commercial Other <br /> Number of living units'. Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: i No. Compartments <br /> - -Q -Type l Mfg Gapacity�— <br /> k SEPTIC TANK _Method of Disposal <br /> PKG. TREATMENT PLT. ❑ x <br /> Foundation ;- 1 t"�PrP Line <br /> Distance to n t: Well r . <br /> Tota! length/size <br /> LEACHING LINE ❑ No. & Length of lines I <br /> FILTER BED ❑ . Distance to nearest: <. Well <br /> �� dation Property Line�— <br /> f N <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS tance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> shall not <br /> rules and regulations of the San Joaquin Local Health District. work for <br /> rtify that in the performance Home owner or licensed <br /> ed agent's anna as torecertifies the ecome subject to workman s compensation laws of California." Contractor s1hir ngl oP sub'contra 't is issued,Ing signature - <br /> employ any person <br /> "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman <br /> certifies the following: s compen - <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. gg <br /> Title: Date:�c <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> ' - Date ?^ Area , <br /> Application Accepted b Date <br /> Date <br /> Pit or Grout Inspectio ^� Final Inspection by <br /> Additional Comments: I ❑ Manteca 823-7104 ❑ Tracy 8354M0 Stk 466-8781 0°Lodi 369-3821 <br /> mit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95101 <br /> Applicant- Return all copies to: Environmental Health Per <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO d1 d`]��J <br /> . 3 3 s�- cis O/ s-7 37 <br /> + EH 13-24(REV-t 5) <br /> EH 14-28 <br />