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lo, " b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 4 <br /> r (Complete in Triplicate) <br /> and/or install the work herein described.This application <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct Joaquin is <br /> Rules and Regulations of the San JoaJoaquinmade in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the in <br /> Local Health District. l <br /> PM <br /> City � <br /> City rt Lot Size <br /> Job Address •J v /� ���^` <br /> a /" Phone <br /> l�In/a <br /> Owner's Name Address I <br /> Contractor �� G t' 35&t 35&1> Address <br /> �/L �etvlS�l License No. L Phone r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Y <br /> / SYSTEM REPAIR- ❑ OTHER ❑ <br /> PUMP INSTALLATION I� <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ In ustriaV Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing . ���EE' Specifications ®® \' <br /> omestic/Private ❑ Gravel Pa 1. ❑ Tracy Depth of Grout Seal _' + Type of Grout — <br /> f 7 Other Cl Delta <br /> I'] Public -,J " Surface Seal Installed by <br /> l _..Approx. Depth I 1 Eastern � State Work Done— <br /> I I Irrigation <br /> Repair Work Done ❑ Type of Pump -- H.P. (-} <br /> Sealing Material)top 50'1 �1 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I_i aNailabPerwiihin 20c system 0 feet.) <br /> Installation <br /> if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> ! Number of living units: Number of bedrooms <br /> Water table depth <br /> ^ Character of soil to a depth of 3 feet: No. Compartments <br /> 1 ❑ Type/Mfg Capacity ry <br /> SEPTIC TANK Method of Disposal -,-r <br /> v-1 PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P Y <br /> Size Number <br /> i I Depth I <br /> SEEPAGE PITS , Property Line <br /> SUMPS L1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l 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 San Joaquin Local Health District. work for <br /> Home owner or licensed agent's signature certifies the t <br /> become subject Ito wlorkman's coympensation performance <br /> ews of Califorrni the <br /> Contractor's which <br /> rhir hiring or sub-contracting d. lsignatuore <br /> employ any person in such manner <br /> I certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins coons. Complete drawing on reverse std , <br /> IF Title: —� �`7 Date: <br /> Signed X <br /> I FOR DEPARTMENT USE ONLY <br /> Date Area <br /> i Application Accepted by <br /> Date <br /> Pit or Grout Inspection by <br /> Final Inspection by Date <br /> Additional Comments: rl <br /> ❑ Stk 466-6781 0 Lodr 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> ! Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i CK RECEIVED BY DATE PERMIT NO. <br /> ff AMOUNT DUE AMOUNT REMITTED CA/S_H <br /> ! iV I ,O /t/s..� ` <br /> �EH 1344 IFIEv.��e sl ! J� <br /> EH 14-26 �" <br />