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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA E <br /> Telephone (209) 466-6781 9 <br /> .PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> Application is hereby made to the San Joaquin quinO Local nCe Health 549 fpf s°f age or permit <br /> No. 1862 for we the/or install the work and the Rules and IR Regulations of the Sancation is <br /> Joaquin ; <br /> made in compliance with San Joaquin tY <br /> Local Health District. f <br /> Lot Size PM <br /> Job Address ' <br /> 'r Phone f <br /> Address <br /> l Owner's Name _ r�7 <br /> • f'�' �'"' "`-"" - �� Address- a � � � � �� License No. <br /> ContractorDESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLAC ENT ❑ - - <br /> TYPE OF WELLIPUMP: SYST REPAIR M OTHER ❑_ <br /> PUMP INSTALLATION <br /> C1 ,pROP. LINE <br /> { SE ER L{NES <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK �— AG ICULT E WELL OTHER WELL PITSISUMPS f <br /> t ',f 1 FOUNDATION <br /> CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM pia. of Well Excavation Dia. of Well Casing <br /> I ❑ Open Bottom ❑ Mantec <br /> ❑ Industrial a � Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing <br /> Cl D is Depth of Grout Seal Type of Grout <br /> -1-1 Public Z ❑ Other - <br /> I Irrigation ✓ -Approx. Depth I astern Surface Seal Installed by +� <br /> Repair Work Dane ❑a Type of Pump H P State Work done <br /> Seal ng'Material (top 50') <br /> Well Destruction ❑ Well Diameter , <br /> f Depth Fiiler'Material (Below 50') <br /> em Pe <br /> TYPE OF SEPTIC WORK: :NEW INSTALLATION 1 REPAIR/ADDITION 1 1 DESTRUCTION I I avlailseptic Syst 200 feet iF public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> 10 Water table depth <br /> ' Character of sail to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mf Capacity <br /> ► SEPTIC TANK g Method of Duos <br /> PKG. TREATMENT PLT:.0 �# r Property Liiie" .. <br /> r Distance to nearest: Well .- Foundation <br /> fZ Total lengthlsize <br /> F LEACHING LINE..,..r.:�. Q--�No:-&Length of lines <br /> ' Foun`da[ion ' �TProperty Line <br /> FILTER HED EJ Distance to nearest: Well <br /> 1 Jj 2 <br /> Size Number <br /> SEEPAGE PITS I 1 Depth pro ert Line <br /> SUMPS Ll "Distance to nearest: Well B fir: FoundationP y <br /> t <br /> DISPOSAL PONDS ❑ "' <br /> I hereby certify that I have prepared this applidation 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. <br /> Home 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 signature <br /> shall not <br /> employ any person in such manner,as_to.bacome subject to workman`s compensation Laws of California." Conirachiring <br /> subjecrt to workman1scompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,f shall employ persons <br /> I tion laws of California." _ <br /> The applicant mu cat( r•'all )red inspec ns. Complete drawing on reverse side. <br /> F <br /> Title: Date: d- <br /> Signed X <br /> s — -� <br /> F 4tTMENT USE ONLY <br /> Date <br /> Area <br /> Application Accepted by 1ate <br /> j� � <br /> r Date�` Final Inspection b ate <br /> Pit or Grout Inspection r <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 [1Manteca 823=7104 ❑ Tracy 835-6385 <br /> Ne <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH I <br /> INFO <br /> ..EH 13-24 IREV.1/n 51 (`�}r � o1,tO S9 { <br /> EH 14.26 <br />