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APPLICATION FOR11PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FRIOM DATE ISSUED <br /> (Complete in Triplicate) <br /> 'l. . <br /> ealth District for a <br /> construct and/or install the work herein <br /> . This <br /> made <br /> Application fiance made <br /> Sano the San Joaquin Counguin ty Ord'nalncle No.549 for sewage or permit <br /> No.1862 for weW pump and the Rules and Regulations of he Sanapplication <br /> Joaquin <br /> made in P <br /> Local Health District. i i <br /> I <br /> r �SC�IG/���/ 6r4 T� /�t� City Lot Sizes c PM <br /> Job Address / v` <br /> �� f�iPt917llGTS %�r1G. S E Phone 'GG <br /> Owner's Name P� /J 1✓! r'DYL�$� Address <br /> 4Z C7 7 4 Phone <br /> I Contractor F �, W Address , 4 �4,3 4:left License No.�_._�__ <br /> TYPE OF WELL/PUMP: 'I� NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> iEWER LINES I_�ti.DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> I FOUNDATION A RICULTUR ELL? OTHER WELL PITS/SUMPS <br /> INTENDED-USE-�- ;-TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> f LlY Industrial ❑ Open Bottom ❑ Mantec <br /> ❑ Tra ype of Dia, of WeH Excavation <br /> T f Casing Specifications <br /> r <br /> Ll Domestic/Private GZ Gravel Pack Type of Grout <br /> k CI Public (l Other 1 Ita D th of Grout Seal <br /> ' I I Irrigation I11'-.Approx. Depth 1 Eastern Su ce Sea[ Installed by <br /> k I H.P. <br /> State Work Done <br /> Repair Work Done ❑ Typh of Pump �J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') { , <br /> Depth Filler Material (Below 501 <br /> RK: NEW INSTALL <br /> TYPE OF SEPTIC WATION I1 REPAIR/ADDITION VT DESTRUCTION I I (No se ptic system <br /> m rented if public sewer is <br /> availar <br /> Installation will serve: Res�+I�ence' Commercial! Ocher r P�/&4,/C <br /> Number o1 <br /> I living units: ill Number of bedrooms <br /> i1 WaAPth <br /> Character of soil to a depth��of 3 feet: �L Q '� <br /> SEPTIC TANK ❑ EType/Mfg — /^�G Capacity No <br /> Me <br /> PKG. TREATMENT PLT. El <br /> Distance to nearest: Well Foundation Property <br /> 1 k, <br /> M <br /> I LEACHING LINE ❑ .No. & Length of lines '>C!S 7Total length/size <br /> •y <br /> FILTER BED ❑ Distance to nearest: Well Foundation PropertyNumberSEEPAGE-PITS-­ -. Depth �SSizeSUMPSr© :Distance to nearest: Well Foundation Property <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 /> rules-and-regulations-of-the 'an Joaquin Local Health District. <br /> t <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ploy Contractor's hiring <br /> to workman's compensa- <br /> { certifies the following:"I certify that-in-the-performance of the work fol which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applicant must call r.all required inspections-Cam late-drawing on rover se�side. <br /> 1� Title: Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> E <br /> ' 1 Date Area <br /> Application Accepted by f _ <br /> II� _ Date Final Inspection by Date <br /> Pit or Grout Inspection by III -. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit7S{ervices 1601 E`! Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK <br /> FEE AI OUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> i, EI <br /> +.EH 13-241REV.1/95) t 0 QA "C, <br /> EH 14-26 I .. - . <br /> i <br />