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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE.,-STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)ith �. <br /> .This application is <br /> Application is"hereby madeto the a County Ordinal cal Hea o.District49 for sewage or permit <br /> 1862 for welt//pump and the Rules and Regulations of he Sari Joaquin <br /> made in compliance with S qLx - <br /> Local Health District. <br /> D L� • � City Lot Size /45 PIVI <br /> Job Address <br /> Address U Phone <br /> %iCJ <br /> Owner's Name _ <br />' �� License No.��� Phone <br /> Contracto�-, i Address DESTRUCTION DMNEW- L� Q "" WELL REPLACEMENT ❑TYPE OF`, UMP:"" <br /> �— -- SYSTEM REPAIR ❑ OTHEl ❑ ` <br /> PUMP INSTALLATION ❑ f <br /> DISPOSAL FLD. POOP. LINE <br /> zw <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL } <br /> I I r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ) i <br /> Dia. of Well Casing <br /> { ❑ Industrial ❑ Open Bottom <br /> El Manteca Dia. of Well Excavation Specifications i <br /> ED Domestic/Private ❑ Gravel Pack El Type of Casing, <br /> ❑ Delta Depth of GroutfSeal Type of Gr t <br /> El Public ❑ Other t <br /> pprox. Depth ' E3 Ea Surface Seal Installed by I <br /> El irrigation �rN i State Work Done <br /> Repair Work Done ❑ Type of Pump H.P• C� <br /> I, Sealing Material ltop 50;fi.` <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> ,5 ,-k�Qepth t� <br /> TYPE OF SEPTIC>WdRK>; hiEW INSTALLATION ❑ REPAIRlADD1TION*� DESTRUCTION ❑ avail available in 200 feet.) if public sewer is <br /> <C_ i <br /> Other } <br /> Installation will e: Residence Commercial f j <br /> Number of living units: - Number of bedrooms Water table depth` f� <br /> Character of soil to a depth of 3 feet: - -- <br /> g i Capacity No. Compartments <br /> SEPTIC;TANK ❑' Type/Mfg _ <br /> I � Method of Disposal <br /> PKG. TREATMENT PLT:"❑ Property Line <br /> Distance to nearest: 3 We j Foundation <br /> t f � Totallengthlsize ' <br /> LEACHING LINE No. &Lengthtof lines t <br /> y undation � ~Property Line��� <br /> FILTER.SED f D Distance t nearest: Well <br /> f Number <br /> SEEPAGE PITS i y.HCl,, Depth Size t <br /> I ftµ.. '` - Foundation r Property Line <br /> SUMPS zN0 'Distance to nearest: Well <br /> DISPOSAL PONDS ❑ !I <br /> 1 hereby certify/Ithat I have prepared thiapplication and that the work will be done in acco <br /> s rdance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District: 1 <br /> Home <br /> lo Danner erslon n suchmanna gas torbecome subjects to workman's ckompensfy that in ation laws;othe f Califorrnia." Contractor's or sub contraire ngi signlatu�e <br /> certifies the ollowing:''I certify that in the perfbrmance'of the work for.which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must_call for II re ins ctons. Complete.dral on reverse side. f <br /> j b Date: *27 —4- <br /> Title: -- ' <br /> Signed X <br /> -FORDEPARTMENT USE ONLY <br /> # ;_ to /1e' Area <br /> I Application Accepted by' _ � <br /> f n. <br /> Date Date <br /> Pit or Gtout Inspection by <br /> Final Inspection by <br /> { Additional Comniie`nts: <br /> LD X466-6781 L3Lodi " M-3621 ElManteca 823-7104 ❑ Tracy 835-&385 Stk., CA 95201 <br /> Applicant Rturn all copies to: Environmeazelton ntal Health Permit/Services 1601 E. HAve., P.O. Box 2009, <br /> �. I <br /> o <br /> RECEIVED-B — <br /> .--DATE-- -PERI 'NO <br /> t FEE AMOUNT DUE, AMOUNT REMITTED:—CASH°^^ - <br /> u. - CA-- - <br /> -" ; . .* t --• u ' ---. -_ A-5 <br /> EH 1344-ill�n 5_7m,M.,.. _ ,....�w. �' — _ _a1�•='1 <br />