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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) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' (Complete in Triplicate) { <br /> Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local County 549 for sewage or No. 1862 for weii/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Ordinance <br /> Local Health District. 4. <br /> City �! _ Lot Size PM <br /> Job Address <br /> ? Phone <br /> Owner's Name M /1�'iLLE� Address <br /> Contractor's Name �' License No. <br /> _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El t <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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> F] DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing <br /> 11 Public <br /> ❑ Other . ❑ Delta Depth of Grout Seal Type of Grout <br /> t) <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by - 1" <br /> r -�---H:P-- — --..�,...—_-_State Work-Done— <br /> . <br /> Work-Done <br /> —Repair-Work-C3one--r❑---Type-of-Pump°---- <br /> Well Destruction L2 . Well Diameter. Sealing Material (top 50'1 <br /> i Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC'WORK:—NEW-INSTAL-L-A'TION-O—REPAIR/.ADDITION-O--DESTRUCTION 9---available4N {wt sin 200 permitted is Installation will.serve: Residence Commercial_ OtherNumber of living units: � Number of bedrooms _ �Character of soil to a depth of 3 feet: '- E� VIlat r table depthij <br /> . /� <br /> Capacity -- No. Co.,m artments <br /> j SEPTIC TANK' l �' Type/Mfg. ` <br /> , - Method of Disposal y, <br /> PKG. TREATMENT PLT. <br /> Ll <br /> Distance to nearest: Well Foundation ► � Property Line <br /> i ? LEACHING LINE; No. & Length of lines <br /> —r" rr %= Total length/size <br /> FILTER BED ❑ Distance to nearest: We11 Foundation <br /> Property Line <br /> p, ;Jc T Number <br /> { SEEPAGE PITS ❑ Depth F Size—, IT— <br /> II SUMPS° Distance to nearest:' Well Foundation S' Property Line _— <br /> DISPOSAL PONDS ❑ -` � - - -� -~�- - ~~'� i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou`nt`y ordinances, state laws, and <br /> rules and regulations of the San Joaquin LocaLHealth District. -_• <br /> Home owner or licensed-agent's—signature certifies the following: "I certify that in the',peiformance of the work for which this permit is issued, I shall not <br /> to <br /> employ any person in�such manner as become subject to workman's compensation laws of CallfOrniO-"Contractor's hiring or sub-contracting signature <br /> certifies the following:!"�I certify that in the performarice of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California."i <br /> k for I6 re inspections. Complete drawing on <br /> The applicant must call <br /> s Title: Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> ?�' Date �•" [ Area <br /> Application Accepted by J� <br /> it <br /> 2- Date Final Inspection by <br /> L�-- <br /> Date <br /> { Pit or Grout Inspection by. ' <br /> Additional Comments: <br /> ❑ Stk 466-6781: ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> _ EINFO. <br /> AMOUNT DUE" AMOUNT flEM1TTED' CASH RECEIVED BY--- -DATE PERMIT NO. <br /> 1+ EH 1324[REV.10/83) _L{S C� <br /> EH 14.25 1 - <br />