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� — r <br /> t l�( <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ` <br /> PERMIT-EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) (VV <br /> rrdescri <br /> /or in <br /> all the work here <br /> ib .TNs <br /> cat <br /> madon is <br /> einti <br /> nticompliaerebynce with SanoJ1 aqu nthe SanCounty Ordinance No.Joaquin Local HealthQ549 for sewage or't to No. 1862 for well/dwell/pump and the Rules and'R gu ations of he San'Ja'quin <br /> Local Health District, 1p <br /> 9 l-�/l zi[ City Lot Size D Q�C"'d-7 PM <br /> ��� �' <br /> Job Address <br /> ` Address C7 cot Phone �r <br /> Owner's Names <br /> v�� � Phone (o n <br /> Contractor's Nam License No. _ — <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR EJ OTHER L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ED Open Bottom ❑ Manteca-- __ ,,Dia. of Well Excavation_ <br /> Type of Casin Specifications <br /> El Domestic/Private 13 Gravel Pack El Tracy yp g Type of Grout <br /> ❑ Public �❑ Other El Delta Depth of Grout Seal yp �► <br /> LlIrrigation - --Approx. Depth LlEastern Surface Seal Installed by <br /> Repair Work'Qone C7 , Type of Pump H.P. State Work Done _ �. <br /> Well Destruction, ❑ .-Well Diameter Sealing Material {top 501 J, <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIONEl DESTRUCTION El (No <br /> c s in septic rented if public sewer is tT1 <br /> Installation will serve: Residence_ Commercial Other l <br /> Number of living units: NumAobed,�.r �� 4-Character of soil to a depth of 3 feetWater table depth <br /> SEPTIC TANK �TypelMf Capacity No. Compartments N <br /> PKC. TREATMENT PLT. ❑- s -� f �.� f 1 Method of.Di�posal .- <br /> - Distance-to nearest: Well 5L0)- Foundation Q Property Line <br /> qD Total length/sizeoX <br /> LEACHING LINE LW No. & Length of lines <br /> a <br /> FILTER BED ❑ Distance to nearest: Well s�0f Foundation�� Property Line .— <br /> _ �. <br /> SEEPAGE PITS � Depth Size '' Number <br /> SUMPS ❑ Distance to nearest: Well/0Q °.— Foundation E6— Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state caws, 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." Contractor's 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 /> tion laws of California." <br /> The applicant st call fo all r uired inspections. Complete drawing on rev ida. <br /> D <br /> Title: 11� ate: <br /> Signed (� <br /> FOR DEPARTMENT USE ONLY L <br /> Date � �-�- Area <br /> Application Accepted by ��� <br /> P Dat -t5- Final Inspection by —,T Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant- Return all copies to: Environmental Health Perefn/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE RECEIVED BY DATE PERMIT"NO. <br /> INFOAMOUNT DUE AM:=CK <br /> + EH 1324{REV.10183? 3� S <br /> EH 14-28 °� <br />