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APPLICATION FOR PERMIT �. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE_ STOCKTON, CA <br /> Telephone (209) 466-6785 <br /> "PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> andloApplication is hereby made to the San Joaquin Local Health District for a.permit to construct ell/p- install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r PM <br /> l City *5 Lot Sire i p <br /> Job Address �'` 3 ���I Q <br /> ,.S . Phone <br /> Owner's Name <br /> License No. -- , Phone <br /> Address DESTRUCTION <br /> Contractor-��-� WELL REPLACEMENT ❑ <br /> NEW WELL El OTHER ❑ <br /> TYPE OF WELL/PUMP:. SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION 11PROP.FLD. PROP. LINE <br /> SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL . OTHER WELL <br /> FOUNDATION -- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of We <br /> ll Excavation Specifications <br /> ❑ Industrial Type of Casing <br /> L) Domestic/Private LI Gravel Gravel Pack Type of Grout <br /> C1 Other ❑ Delta Depth of Grout Seal <br /> 1`7 Public Surface Seal Installed by <br /> ti i I Irrigation ,.Appro` H.P. �-� <br /> Depth i I Eastern State Work Done <br /> .. <br /> Repair Work Done ❑ Type of Pump Sealing Material )Loft 501 <br /> Well Destruction Well Diametyer <br /> Depth�... Filler Material (Below 50'1F <br /> available within 200 feet.) <br /> T E OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION !.I DESTRUCTION ! 1 (No septic system permitted if public sewer is <br /> Installation wr <br /> Residence r Commercial, Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 fee . Capacity No. Compartments <br /> ` SEPTIC TANK ❑ Type/, ;,9 Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ tF ndation Property Line <br /> Distance to nearest: Well <br /> } length/size <br /> LEACHING LINE ❑ No. &'Length of lines r Line <br /> FILTER BED El Distance to nearest: Well <br /> Foundation <br /> 4 <br /> Size Number <br /> Si <br /> SEEPAGE PITS i I Depth l Property Line <br /> [ Foundation <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ } <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 /> ermit is issued, <br /> rules and regulations of the San Jaquin Local Health Disirict.g <br /> Home owner or licensed agent'net signature toe some subject Ito workman's rtcompensation Isewsoof Galifo�n ah Contractor srhu ngl op sub cont actinglsignatushall �e <br /> employ any person in such man ers's h ring o to workman's compensa- <br /> C certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ psubject <br /> tion laws of California." on reverse side. '�/7 y <br /> The applicant sit call for all required in tions:-Complete drawing Date: ` O 7 <br /> Title: % <br /> 1 Signed X <br /> FOR DEPARTMENT USE ONLY `0 <br /> Date � <br /> iILL -� <br /> Area ;a1.r <br /> Application Accepted by Date ' <br /> k Pit or Grout Inspection by <br /> Date�1 Final Inspection by 1 <br /> l Additional Comments: t <br /> ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823 7104 [1 Tracy 535-6385 Stk., CA 95201 <br /> I Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> IL I CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED GACH <br /> r INFO � / <br /> + EH 13.24 IREV.5/e 51 � � <br /> EH 14-28 <br />