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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 R <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> u (Complete in Triplicate.), . <br /> permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin I in Local Health District for a pe <br /> f made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wall/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 0.� S Sn City fXG Lot Size PM <br /> Job Address RM r + <br /> (� <br /> Owner's Name Address LL 'C Phone <br /> - <br /> Ir <br /> Address License No. Phone V. <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r PUMP iNSTALLATiON ❑ SYSTEM-REPAIR ❑ OTHER ❑ <br /> i DISTANCE T AREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FI_D. PROP..LINE <br /> ATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL OBLUM AREA CONSTRUCTION SPECIFICATIONSDia. of Wf Well Casing <br /> 1 <br /> E Industrial ❑ Open Bottom 0 Mante <br /> • <br /> • Specifications <br /> 1:1 Domestic/Private ❑'Grave! Paok�� ❑ Tracy Type of a T of Grout <br /> ❑ Public er ❑ Delta Depth of Grout Seal Type <br /> ❑ Irrigation I pprox. Depth ❑Eastern Surface Seal lristalled by <br /> Repair Done ❑ Type of Pump H.P. State Work Done <br /> ' Well'Destruction ❑ WellDiameter Sealing Material (top 501 <br /> I Depth Filler Materia! (Below 501 <br /> x TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ iDESTRUCTION C1 (No <br /> septic sy te200 feettted'rf public sewer is <br /> r Installation will serve: Residence_ Commercial_O Other,— <br /> E <br /> Number of living units: Number of bedrooms- I .N— Water table depth <br /> , <br /> Character of soil to a depth of 3 feet: <br /> f. Ca ci -' — No. Compartments <br /> SEPTIC TANK ❑lI Type/Mfg �- � � <br /> { .- Method of Dispgsa <br /> l <br /> PKG. TREATMENT PLT. ❑ 4 7" <br /> Distance to nearest: Well r Foundation Property Line <br /> 1 LEACHING LINE W1,; No. & Length of lines Total length/size <br /> FILTER BED ❑,1 Distance to nearest: Well Foundation q: Property Line — <br /> i <br /> Number <br /> SEEPAGE PITS [I' Depth Size w, <br /> ❑ Distance to nearest: WeA t:::!k Foundation i Property Line <br /> SUMPS - <br /> { �DISPOSAL PONDS ❑� 1 <br /> I hereby certify that I have prepared this application and that the work Q11-be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the' Joaquin Local Health District. `, � ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that k,,the'performance of the work for which this permit is issued, I shall not <br /> signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contract os Kiring or sub <br /> subject t workman'-contractrs ompensa <br /> certifies the following:"I certify that in the performance of the work for which this-permit is issued <br /> I shall employ pe <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. ! <br /> , � �/,tr+/ Title: ( 7 Date: <br /> Signed <br /> f � ^--a-u4 �-o <br /> s I .� <br /> ! _ OR DEPA�i7MENT USE ONLY �� <br /> Date Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by,l Final Inspection by Date�. <br /> I Additional Comments: <br /> LlStk 466-6781 ❑'gLodi-369-3621 ❑ Manteca 823-7104 ❑ Tracy 635 6385 <br /> Applicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED 8Y DATE PERMIT`NO. ' <br /> J. K INFO - AMOUNT.DUER AMOUNT RE.M. ED_ _ —CASH <br /> + EH 13-241 REV.1/85) ih _ <br /> EH W28 <br /> _ ii <br />