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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ' I <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby <br /> made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> 9 for sewage or No. 1862 for well/pump and the Rules and Regulations <br /> made in compliance with San Joaquin County Ordinance No.54of the San Joaquin <br /> Local Health District. <br /> 1 � ��• city <br /> Lot Size PM <br /> Job Address le <br /> Phone <br /> Address <br /> Owner's Name <br /> License Noe 9 <br /> +�9�� Phone» I <br /> Contracto .. Address�1�—�'��� <br /> NEW WELL ❑ '' W�tL REPLACEMENT El DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM-REPAIR fA- OTHER ❑ <br /> PUMP INSTALLATION <br /> SEWER LINES �—�—.— DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> _FOUNDATION _ _ . AGRICULTURE WELL. _ <br /> L� t CONSTRUCTION ECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA SPDia of Well Casing <br /> 13- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well,Excavation Specifications <br /> Type of Casing <br /> Domestic/Private ❑ Gravel Pack 17 Tracy Depth of Grout Seal Type of Grout <br /> I', Public <br /> nOther C1 Delta _ <br /> ' A rox.fDepth l i Eastern Surface Seal Installed by <br /> I Irrigation _ ppr—Pt— H.P. _Olt� State Work Done <br /> V a <br /> Repair Work Done Type of Pump Sealing Material (top 501 <br /> Well Destruction ❑ WL-11 Diameter <br /> 1 1 I Filler Material I0e1ow 50') r <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRIADOITIDN l 1 DESTRUCTION l l aNailableseptic <br /> wthin 200 feet.) it public sewer 1s <br /> Installation will serve: Residence�� Commercial— Other I L <br /> %,Niimber of living units: Number of bedrooms 'Water table depth C <br /> '`Character of soil to a depth of 3 feet: Capacity— No. Compartments <br /> f SEPTIC TANK " ❑ TypelMfg ' <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> t <br /> I • Total length/size <br /> i w ❑ No. & Length of lines <br /> LEACHING LINE <br /> Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> ,, '" F` Number <br /> SEEPAGE`'PITS I 1 Depth Size <br /> Foundation Property Line .„ <br /> SUMPS LJ Distance to nearest: Well„ v _ <br /> .,,;;rDISPDSAL-PONDS O ”' <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. - <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 laws of California." Contractors 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 /> 1 tion laws of California." <br /> The applicant must C211 or all requir�d inspections. Complete drawing on reverse side. O <br /> Title: Date: _4 <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date Area 4P <br /> i Application Accepted by Q <br /> Date <br /> Pit or Grout Inspection by Date <br /> Final Inspection by <br /> Additional Comments: 3621 ❑ Manteca 823-710 ❑ Tracy 836-6385 <br /> El Stk 466-6781 ❑ Lodi 369 4_ <br /> t ironmental Health Permit/Services 1601-E.. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to- Env <br /> CK RECEIVED BY DATE PERMIT NO. <br /> nEEAMOUNT DUE AMOUNT REMITTED CASH <br /> i E14 13.24 tREV. <br /> EH 14-2e <br />