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'IV U <br /> APPLICATION FOR PERMIT '"El <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> IJG O ��90 <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> all the work <br /> cation <br /> rAnadle nticompkhance wrth San Joaquin nthe n County Ord nance No.549 for sewage or uin Local Health District for a permit <br /> Na 1862 for well/dpumlp and the Runes and fft Regulations of This <br /> he San l Joaquin <br /> Local Health District. a <br /> City Lot Size PM <br /> Job Address _ l <br /> Address "�-- Phone <br /> Owner's Nam I ��l <br /> ` �- -�� icense No Gam" Phone��-r <br /> Contractor �—Address _��$�'r� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11DESTRUOCT OR EJ <br /> 1-1 <br /> MP INSTALLATION ❑ SYSTEM REPAIR <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES... ' DISPOSAL FLD. POOP, LINE G <br /> FOUNDATION AGRICULTURE WELL ""`' -OTHER WELL PITSISUMPS IJ <br /> INTENDED USE TYPE OF*WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation O <br /> r Type of Casing Specifications - <br /> Y.Rpmestic/Private ❑ Gravel Pack ❑ Tracy yP <br /> ❑ Other ( 171 Delta Depth of Grout Seal Type of Grout <br /> M Public t <br /> l I I Irrigation �_Approx. Depth,,- I I Eastern Surface Seal Installed by r r <br /> k State Work Done <br /> It Repair Work Done �h Type of Pump H.P. [��''-Q-'�- <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 501 <br /> Depth k Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l 1 .DESTRUCTION I } avlailablelwithin 200 feet't�ed it public sewer is <br /> k <br /> x Installation will serve: Residence— Commercial— Other <br /> i <br /> Number of living units: Number of bedrooms <br /> +ot soil to a depth of 3 feet: Water table depth <br /> SCharacter EPTIC TANK ❑ Type/Mfg N. Capacity No. Compartments <br /> � z'� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ s ., 4 <br /> Distance 6 nearest:-Well• -- _Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i 9 <br /> C SEEPAGE PITS l 1 Depth r l Size Number <br /> SUMPS [IDistance to nearest: Well Foundation. Property Line <br /> DISPOSAL PONOS ❑ <br /> 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 /> 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 cornReensatioriPws 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." .I <br /> The applicant mu ca all required inspections. Complete drawing on <br /> Qnreverse side. +� + <br /> Signed X <br /> Title: Date: 2_ ^ <y <br /> L <br /> JOR PARTMENT USE ONLY <br /> ! + Date Area <br /> Application Accepted by <br /> F Date Final Inspection by w Date D <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: Envi{ronmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ..CASH r) RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> �.EH13-24(HEV.t/es) <br /> EH t1-26 <br /> I <br />