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i. <br /> I <br /> APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,-TON AVE., STOCKTON CA <br /> Telephone {209) b' 3 <br /> PERMIT EXPIRES I'YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> I District for a ali the work herein <br /> . This <br /> is <br /> Application is lance ma a to the San <br /> n Cou Joaquin <br /> LocalHealthnce No.549 for sewage or permit to <br /> 1862 forconstruct and/or <br /> and the Rules and Regulations of the Sen Joaquin <br /> made in comp � ` <br /> Local Health District. 1� <br /> eT City Lot Size ( PM <br /> Job Address / �f <br /> �� r �i7��+!� Phone 9L <br /> Owner's Name �I Address <br /> Y License No._Phone_ <br /> Contractor Address • <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR fl OTHER El <br /> SEWER LINES DISPOSAL. FLD. PROP. LINE <br /> IQ EAREST: SEPTIC TANK - <br /> FO AGRICULTURE WELL OTHER WELL PIT <br /> SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROB A Wel! Excavation Dia. of Well Casing <br /> El Industrial ❑ Open Bottom nteca <br /> T e of Casing Specifications <br /> ❑ Domestic/Private ❑ ack ❑ Tracy Type Type of Grout <br /> I-I Other Cl Delta Depth of Grout Seal <br /> f'1 Public - <br /> i I I Irr' - n ­Approx. Depth I 1 Eastern <br /> Surface Seal installed by <br /> F H.P. State Work Done— <br /> epair Work Done 11Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION aNailablleseptic <br /> wit in 200 feet.) if public sewer is <br /> r <br /> installation will serve: Residence_ Commercial— Other <br /> I <br /> Number of living units: Number of bedrooms Water table depth <br /> ! Character-at soil to-a-depth-of-3-feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK d Type/Mfg_ Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Pro ert Line r i <br /> Distance to nearest: Well Foundation Property <br /> Total length/size <br /> f LEACHING LINE ❑ No- & Length of lines Y <br /> I Foundation Property Line <br /> FILTER BED ❑ Distancetto nearest: Well v7 <br /> w I '­ <br /> SEEPAGE PITS I I Depth Size Number 7— <br /> ' Foundation Property Line <br /> SUMPS LI Distance to nearest: ~Well' <br /> DISPOSAL PONDS ❑ <br /> 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 San Joaquin Local Health Diltrict. <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 shall not <br /> employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature <br /> 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 /> I The applican t cal! for all re uir d i pections. Complete drawing on reverse side. <br /> Title: <br /> Rate: <br /> Signed X <br /> F FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by Date Finale Inspection by <br /> 3 <br /> Additional Comments: <br /> 0 Stk 466-6781 E) Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-&385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 13 <br /> 1r <br /> -EH 13-24 JREV.1/Kr,) - _ <br /> EH 14.2e - x <br />