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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I Telephone (209)1466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,� .,•. . - �,. +s`" ��' <br /> (Complete in Triplicate) ��w t <br /> .,°93.` .,.r ` lication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. s app l <br /> made in compliance with San Joaquin COL <br /> Ordinance No.549 for sewage or No. 1862 for,well/pump and the Rules and Regulations of the San Joaquin r <br /> Local Health District `t" a 1 t :�'` <br /> `-� f Lot Size <br /> p a PM <br /> O 3 C �d City <br /> Job Address <br /> t�Lg(j 7 Phone - <br /> y. <br /> —Address ;S <br /> Owner's Name : <br /> License No.__.��Phone <br /> DESTRUCTION ❑ <br /> Contractor Address r <br /> ❑ WELL REPLACEMENT ❑ <br /> NEW WELL t <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ ��� <br /> PUMP INSTALLATION F1 <br /> SEWER LINES ��— DISPOSAL FLD. PROP. LINE <br /> t A <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> ON <br /> FOUNDATI <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Wel: Excavation <br /> ❑ Industrial ; ' : Specifications 1, <br /> ❑ Tracy Type of Casing ` r <br /> ❑ Domestic/Private ❑ Gravel Pack - depth.. Grout Seal ' _ 4 Type of Grout ' <br /> �— ---"" ❑-0ftier"— "�.Delta�' j <br /> ❑ Public <br /> ` <br /> Approxk,Dpth <br /> _� e '.'�`.TEastem Surface Seal Installed by <br /> ❑ Irrigation t <br /> State Work Done— <br /> Repair Work Done LI Type of Pump <br /> H P t <br /> Sealing Material (top 50'1 <br /> I ' Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth t <br /> TYPE OF SEPTIG WORK: NEW INSTALLATION ❑ REPAIRIADDITlON ❑ DESTRUCTION availablelw th ne200 feettted if pubic sewer is <br /> r A, <br /> Installation willserve: Residence Commercial other <br /> Number of living units: Number of bedrooms y Y�-*': <br /> I Water table depth <br /> Ei Character of soil to a depth of 3 feet: Capacity No. Compartments j <br /> I <br /> SEPTIC TANK Type/Mfg _ - t] <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ jiVIProperty Line : <br /> Distance <br /> to nearest: Well Foundation - <br /> r ) , <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Line ` <br /> Property <br /> FILTER BED ❑ Distance Foundation e to nearest: Well p <br /> iI <br /> `/ Number ? <br /> SEEPAGE PITS }7� Dept Size <br /> � r � Foundation Property Line <br /> SUMPS 1:1 Distance to nearest: Well <br /> DISPOSAL PONDS ❑ 1 til <br /> r <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 Yaws;-and <br /> rules and regulations of the San Joaquin Local Health District. <br /> g <br /> Home owner or linea ssach manne>gas to becomfe subject ies the Ito workman'srtcompensation lify that in the awsoof California.- Contractors rhir hiring or sub-contract sub-contracting <br /> employ any pe <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 /> j The applicant must call for all required inspections. Complete drawing o reverse side. ��o <br /> Date: <br /> Title: <br /> Signed ; <br /> FOR DEPARTMENT USE ONLY - <br /> Date � Area O <br /> Application Accepted by <br /> Date <br /> Date ,Final Inspection by <br /> Pit or Grout Inspection �.+ - <br /> Additional Comments: 5385 <br /> ` [3 Stk 466-6701 ❑ Lodi 369 3621 ❑ Manteca 04 ❑ Tracy <br /> Applicant- Return all copies to: Environmerital Health PermitlServic 'b. Box 2009, Stk., CA 95201 <br /> Senric <br /> as 1601 E. Hazelton A <br /> CK RECEIVED BY " EVATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> d y - <br /> x+ EH 13-24 4REV.5 <br /> EH 14.28 <br />