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APPLICATION FOR PERMIT <br /> Y SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) lication is <br /> mance Na-549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the SanCJoaquinonLdocal Health District for a permit to construct and/or install the work herein described. This app <br /> made in compliance with San Joaquin f <br /> Local Health District. <br /> City Lot Size LIP< PM <br /> Job Address O - <br /> . t � e-r Phone <br /> Owner's Name <br /> C> Address X3.5'•3 <br /> 01 Address <br /> License No. ----Phone_ <br /> Contractor rye--- WELL REPLACEMENT ❑ DESTRUCTIO <br /> TYPE OF WELLIPUMP: NEW WELL ❑ OTHER C3 <br /> - pUMQ INSTALLATION"❑`moi 'SYSTEM REPAIR",17 <br /> DISPOSALFLD,, PROP._,LlNE_ �. <br /> ,SEWER_LINES,,_.—�—" PITS/SUMPS <br /> =DISTANCE TO NEAREST:,FOUN _TANK 4 h AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBL_ EM AREA <br /> CONSTRUCTION SPECIFICATIONS Dia. of Well Casing _ <br /> ❑ Industrial El Open Bottom D Manteca Dia" of Well Excavation Specifications <br /> Type of Casing <br /> ❑ Domestic/Private. El Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> l l Public ❑ Other 1 ❑ Delta <br /> �.-Approx. Depth i I Eastern Surface Seal installed by <br /> I I Irrigation s , State Work Done — <br /> Type of Pump H.P. <br /> Repair Work Done ❑ Sealing Material It0p.501 <br /> Well Destruction ❑ Well Diameter <br /> I Depth I Filler Material IBelow 50'1" 10 <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l i DESTRUCTION aNailabperwi system <br /> 200 feet.) <br /> if public sewer is U <br /> Installation will serve: Residence_ Commercial__ <br /> Other <br /> Number of living units: Number of bedrooms Water table depth ` <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments 4 <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE C3 No. & Length of lines Foundation Property y <br /> FILTER BED El Distance to nearest: Well <br /> i ert Line <br /> I <br /> Size Number <br /> SEEPAGE PITS i I Depthrt � <br /> Ll Distance to nearest: Well Foundation Property Line a <br /> SUMPS <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 San Joaquin Local Health•District: '-rt <br /> ofrn "work for Contractor's which <br /> ithis <br /> P o <br /> or sgrfollowing- <br /> lkrtpe <br /> ov�er le compensation laws Califoia. hrngosub-contracting signature <br /> .employY person in manner tbecome subject workman's <br /> r certifies the following: "I certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 1 The applicant must call for all required inspe tions. Complete drawing on reverse side. <br /> Title: Date: � .. <br /> 1 Signed X POP <br /> F DEPARTMENT USE ONLYl <br /> Date 1 f Area / <br /> Application Accepted by <br /> Date Final Inspection by U <br /> r Date y <br /> Pit or Grout Inspection by . <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy '835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1603 E. Hazelton Ave., P.O. Box 2009, 51k., CA 95201 <br /> CK RECEIVED BY ;;nATE PERMIT"NO.FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> EH 13.24 1 REV-tL-I S I <br /> EH 14-28 <br />