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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCALHEALTH DISTRICT <br /> 1601 E. HAZE' ON�AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 ; s <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rF, J, <br /> )Complete in Triplicate) `. $ application is <br /> stall the work herein <br /> :,. <br /> Application is herebyma <br /> SanJoaquithe nCounty Ordinance No.District i6aquin Local Health 549 for sewage or It to construct and/OF in No,1862 for well/pump and,the Rules and Regulations of the San Joaquin <br /> Y '� f <br /> made in compliance # <br /> Local Health District <br /> City Lot Size •r PM <br /> Job Address <br /> V <br /> Owner's Name' !J 3' - Phone`� -- <br /> _ Address �-� <br /> . i' ,!License No.gf,61 phone <br /> Address 4 i � 1�7 y U <br /> Contractor ❑ <br /> TYPE OF WELL/PUMP: NE1f1!WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION L] PROP..REPAIR � OTHER El <br /> SEWER LINES -�-- DISPOSAL_FLD. _ .�PROP ..LIfVE �h <br /> DISTANCE.TO NEAREST: SEPTIC TANK, PITS/SUMPS <br /> FOUNDATION �� AGRICULTURE WELL OTHER WELL <br /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom tom ❑ Manteca Dia. of Well Excavation_ Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ Domestic/Private El Gravel Pack Depth of Grout Seal Type of Grout <br /> ❑ Other ❑ Delta <br /> ❑ Public � urface Seal Installed by <br /> ❑ irrigation --App State❑ Eastern State Work Done <br /> H.P. <br /> Repair Work Done ❑ Type of Pump — Sealing Materia{ (tap 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Depth I Filler Material {Below 50'1 <br /> fo j "� .available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION,❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence—1 Commercial— Other <br /> Number of bedrooms"`'"— � <br /> Number of living units: ; Water table depth <br /> Character of soil to a depth of 3 feet: Ca <br /> „ �'— �' ! No. Compartments <br /> ❑ Type/Mil U pacity�� J <br /> SEPTIC TANK Y Method of Disposal ' <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> � r <br /> Total length/size <br /> LEACHING LINE ElNo. & Length of lines Foundation Property Line <br /> FILTER BED El Distance to nearest: Well <br /> I , <br /> t Size Number <br /> SEEPAGE PITS ❑ Depth - <br /> ❑ Distance to nearest: _ Well: -Foundation= <br /> ==Property Line <br /> SUMPS = and <br /> - <br /> DISPOSAL PONDS ❑ <br /> i hereby certify that 1 have prepared this application and that the work will�be done in accordance with San Joaquin county ordinances, state laws, <br /> l not <br /> rules and regulations of the San Joaquin Local Health District. ork for <br /> that in the performance} Home owner or licensed agent's <br /> manner signature <br /> tobecomecomes the f Ito ing-. "I certify <br /> compensation Laws of California." Contractor's lhhing orthis psub contractingermit is issued, )signature <br /> Home <br /> employ any person in such m persons subject to workman's compensa- <br /> certifies the following:"I certify that in the performance of the work far which this permit is issued,I shall employ <br /> tion laws of California." A&A4111 rte` <br /> r, The applicant m t call for quired inspections. Complete drawing on se side. <br /> Date: <br /> ' Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date fik Area <br /> �. Application Accepted by Date i b Us <br /> Date — Final Inspection by <br /> Pit or Grout Inspection by <br /> r <br /> Additional Comments: r ' <br /> [IStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return aA'copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 <br /> I RECEIVED BY DATE PERMIT NO. <br /> IFE E AMOUNT DUE AMOUNT REMITTED CASH �S <br /> � _� <br /> EH 13-24 1REV.!./a 5I Y <br /> 14-25 <br />