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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL iHEALTH DISTRICT <br /> 1601 E, HAZELTION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM "DATE ISSUED <br /> I (Complete in Triplicate) <br /> work described.THs is <br /> made in Icompl compliance with SanJoaquin San <br /> County Ordinance No.District48 for sewage or ermINo�1862 for welllpump and the Ruconstruct <br /> sand IRegulaxions of he San <br /> l Joaquin <br /> Conal Health District. <br /> "`) / . CitY <br /> Job Address Lot Size 'c PM <br /> Phone i <br /> Owner's Name `���z� Address <br /> , Phone <br /> 14 Contractor &&k-Address License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ DESTRUCTION LJ <br /> f r PUMP INSTALLATION ❑ SYSTEM REPAIR 1: OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES 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 /> El Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation <br /> Type of Casing Specifications " <br /> ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout- <br /> El <br /> p Public # ❑ Other El Delta W <br /> E3 Irrigation �pprox:Depth 13 Eastern Surface Seal Installed b �1 <br /> j Y H P. —=- State Work Done ;Cl <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction IF ❑ Well Diameter Sealing Material (top 501 <br /> i, Depth 'I Filler Material IBelow 501 <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION 'REPAIR/ADDITION ❑ DESTRUCTION ❑ avail bil witsop ic hin 200 feet.) if public sewe <br /> _;,_Installation will serve: Residence,4!!;f�.Commercial_ Other s <br /> Number of living units: Number,of bedrooms �. Water table depth <br /> Character of soil to a depth of 3 feet* ���� No. Compartments <br /> SEPTIC TANK Type/Mfg �Li Capacity - <br /> .,� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 <br /> ' Distance to nearest: Well Foundation Property Line 1�T_ <br /> v � --c. - ---��•�- -' ' "�Tofal length/size� <br /> LE4CHIN6 LINE Not B&LengtF�of fines <br /> r --Foundation,.�s-__ Property Line <br /> FILTER BED ❑ -Distance to i arest: Well TT <br /> t : <br /> { �� Size Number <br /> SEEPAGE PITS ❑ Depth" -.R•-�•^-___E. Properfy Line <br /> +' SUMPS i ❑ "Distance10-nlearest:— Well" Fou`ndafioit f r <br /> C DISPOSAL PONDS ❑ ! <br /> hereby certify that I have prepared this application and that the work will be done in"accordance,with S n 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 7 s work for ws hiri his psrmit is issued, Isig!1 not <br /> employ any person in such manner as to become subject to workman's compensation.laws""of California."rnaContractor's hiring_or'sub contracting signature <br /> r certifies the fallowing: "I certify that in the performance of the work for which this permit is-Issued;l sFi`all employ personssubjecto'workman's compensa- <br /> tion"laws of California." <br /> TheFapplicant must call fa II re ed inspections. Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> E Signed ,45�"-�do . <br /> FOR DEPARTMENT USE ONLY i <br /> J .Area <br /> Application Accepted by _ `• f'`//� - Date �, <br /> k F t DatB� <br /> Date�- Final Inspection by <br /> Pit or Grout Inspection by F --F---' <br /> �e dditional Comments: _ <br /> t El Stk 466-6761' ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-&W <br /> Applicant="RetuYfi`all comes to:i"i;r_f6 ment5I-He`alth••"'Permit7Services 1601 E.Haiefton}4A ., P,O."Box 2009, Stk.,- A"95201 <br /> FEE_ -._ AMOUNT DUE 4. t..-AMOUNT-REMITTED-�--UASFI '"'x--. 8 ECEIVED BY__.,;'»^DATE _ - PERMIT..NO. - <br /> . ..,.t .o INFO � <br /> 5 / 1 <br /> r EH 13-24(REV.t/65) y�� <br /> EH 14.26 - <br /> ' <br />