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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 <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the <br /> Permit to construct and/or install the work herein described.This application is <br /> Local Health District. <br /> n� ,.. <br /> r <br /> San Joaquin <br /> Job Address <br /> _ w City Lot Size PM <br /> Owner's Name i f��� I <br /> Address ^ .S <br /> k� <br /> Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: Address <br /> NEW WELL ❑ License No. <br /> WELL REPLACEMENT ❑ —`—`—�phone <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ 1 <br /> DIST REST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ �1\In1 <br /> --�� SEWER LINES ��� DISPOSAL FLD. <br /> FOUNDATION PROP. LINE <br /> ELL OTHER <br /> INTENDED USE WELL PITS/SUMPS <br /> TYPE OF WELL' PROBLEM AREA CONSTRUCTION SP <br /> ❑ lndustrfal ❑ Open Bottom �'- S <br /> ❑ Domestic/Private ❑ Manteca Dia. Of Wel! Excavation��` <br /> ❑ Gravel Pack ❑ Tracy T f Well Casing <br /> ❑ Public ❑ Other { Type of Casing <br /> I ❑ Delta Depth of Grout Seal Specification <br /> ❑ Irrigation Approx. 'Depth ❑ Eastern Type of Grout <br /> Repair Work Done ❑ ---Approx. Surface Seal Installed by e <br /> Type of Pump f� H.P. <br /> Well Destruction ❑ Well Diameter I State Work Done - <br /> Depth Sealing Material ftop 50') <br /> TYPE OF SEPTIC WORK; Filler Material (Below 50') <br /> NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system <br /> permitted if public sewer is <br /> Installation wiB serve: Residence Commercial available within 200 feet.) <br /> Number of living units: Other, <br /> Number ofbedrooms ` <br /> Character of soil to a depth'of".3 feet: I <br /> SEPTIC TANK -�' '. <br /> ❑ Type/Mfg 2 Water table depth <br /> PKG. TREATMENT PLT. LlCapacity—_ No!Compartments <br /> Distance to nearest: UVejlw "T -- Method-of Disposal <br /> I �� Foundation property Line. <br /> LEACHING LINE ' u <br /> ❑ No. & Length- of lines <br /> FILTER BED IJDistance to nearest: Well Total length/size <br /> Foundation <br /> P._ � Property Line tl <br /> � 3{ <br /> SEEPAGE PITS ❑ Depth t H^."; <br /> SUMPS Size Number l <br /> ❑ Distance to"nearest: Well I <br /> DISPOSAL PONDS Q ,. _ - Foundation_� Property Line <br /> -•.�. _.....r_,.��gym,, ..,.. <br /> i. <br /> ( hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state la r <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 g such manner i to become subject t workman's compensation laws of California."Contractor's hiring o►sub contraued <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall C to <br /> tion laws of California." g signature <br /> The applicant must call for all re fired inspections. Complete drawing an reverse side. employ Persons subject to workman's compensa- <br /> tion <br /> Signed ����� <br /> Titfe: <br /> Date: i y <br /> FOR DEPARTMENT USE ONLY - + <br /> Application Accepted by <br /> ,:.i Date Area C.L� <br /> Pit or Grout Inspection by <br /> Date Final Inspection by �—f <br /> Additional Comments: Date <br /> ❑ Stk 466 fi781 ❑ Lodi 369-3621 ❑ Manteca <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E❑Hazeiton Ave.. Box <br /> � 2009, Stk., CA 95201 <br /> EAMOUNT DUE <br /> INFO AMOUNT REMITTED CK RECEIVED BY <br /> " - <br />+ EH 13.24{gEV.t/85) �" �" DATE PERMIT"NO." <br /> EH 14-26 .. <br />