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a <br /> APPLICATION FOR PERMIT - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate}Ith - <br /> all the work <br /> n described.This <br /> made in <br /> Application <br /> ante wrade to the ith San Joaquin nJoaquin County OrdinalHea <br /> nce No.District49 for sewage or permit <br /> No. 1662 for we I/pump atnd the Rules and IR gulations of he San'Joaquin <br /> made P <br /> Local Health District. 7_+- _ nAll <br /> ZY %107L.C-/��p City Lot Size PM <br /> I Job Address <br /> tAddress Z� Phone <br /> f Owner's Name ' <br /> Phone <br /> Contractor's Name icense No. <br /> TYPE OF WELL/PUMP: N WELL. El WELL REPLACEMENT E3DESTRUCTION 11 d <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C3OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. ;PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> [I Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specificiltioris�, <br /> 1-1 Domestic/Private El Gravel Pack ❑ Tracy Type of Grout <br /> CJ Public ❑ Other ❑ Delta Depth of Grout Seal yp <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ; <br /> Repair Work Done El Type p Type of Pump State Work Done _Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> f Depth Filler Material (Below 501ed <br /> �? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ElDESTRUCTION-L] <br /> (No sbpeic sy tem rmitp if public sewer is <br /> ed <br /> avaInstallation will serve: Residence Commercial, Other <br /> Number of living units: - Number of bedrooms—02. '" ,. ` R <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg pacity No. Compartments <br /> I Method of Disposal- <br /> PKU. TREATMENT PLT. ❑ -- <br /> Distance to nearest: Well Foundation Property Line <br /> Total"length/size <br /> LEACHING LINE El No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation L t Property Line a <br /> SEEPAGE PITS Depth Size Number_ <br /> SUMPS L3 Distance to nearest: Well oundation 'Property Line L <br /> DISPOSAL PONDS ❑ . , f .� b.. :,r' _ _� .. <br /> 1 hereby certify that I have prepared this application and that'the work will be done in accordance with San Joaquin*county ordinans'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 per - issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub <br /> 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 /> l <br /> The applicant m t call for all required inspections: Complete drawing on reverse side. <br /> Signed <br /> Title: Date:. <br /> r FO DEPAR MENT USE ONLY <br /> Data Area <br /> Application Accepted by <br /> ate � _ Final Inspection by Date �z�r <br /> Pi or Grout Inspection by Q <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 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> } <br /> t � <br /> w FEE CASH RECEIVED BY� f DATE. PERMIT'N0. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> +EH 1 <br /> 3-2a IRI+.101835 S, U l�Z7V <br /> EH 1426 <br />