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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> P /^ 1601 E. HAZE,ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t <br /> Application is hereby <br /> made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This application is. <br /> made in compliance with San Joaquin Gounty ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. } <br /> Lot Size PM ' <br /> City + <br /> Job Address <br /> Phone <br /> L Address <br /> Owner's Name <br /> t v- License No. 16 hone' <br /> Contractor E Address <br /> WELL REPLACEMENT D DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR R_ <br /> SEWER LINES ��-- DISPOSAL FLD. PROP. UNE ai <br /> DISTANCE TO NEAREST: SEPTIC TANK.— OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PR06L_ _EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br />� -❑ Industrial Q Open Bottom ❑ Manteca <br /> pia. of Well Excavation Specifications <br /> Q Tracy ` Type of Casing <br /> VpomesticlPrivate ❑ Gravel Pack Type of Grout <br />` [-1Other D Delta- Depth of Grout Seal <br /> 1-1.Public Surfa a Seal installed by <br /> I I Irrigation __-Approz. Depth l�1 Eastern s State Work Done <br /> Type of Pump H.P. <br /> Repair Work Done *4 <br /> Well Destruction ❑ <br /> Well Diameter Sealing Material (top 50'1 <br /> Depth I Filler Material (Below 50') <br /> F <br /> r available within 200 feet.) . <br /> t TYPE OF SEPTIC WORK: -NEW INSTALLATION I1 REPAIR/ADD)TION I 1 DESTRUCTION I l INo septic system permitted it public sewer is <br /> tCommercial— Other d <br /> Installation will serve: Residence <br /> Number of living units: Number of bedrooms Water table depth <br /> ( Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> t SEPTIC TANK ❑ Type/Mfg' Method of Disposal <br /> I 1 L!" <br /> r PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation r .,. <br /> I .. <br /> Total length/size <br /> r LEACHING LINE ❑ No. & Length of lines Property Line <br /> f ❑ Distance to nearest: Well _ Foundation #, <br /> FILTER BED <br /> umber - <br /> SEEPAGE PITS I I Depth Size <br /> I Foundation Property Line <br /> SUMPS' :� L� Distance to nearest: Well c i <br /> DISPOSAL=PONDS '"\Q.' - <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 7 <br /> ' rules and regulations of the San Joaquin Local Health Dli trict.g work for <br /> Home owner or licensed agent's sig <br /> n such manner anature certifies the s to become subjeolto workman'srtcompensatify that in iorr laws of Califonah"Contractor which shi hiring or sub-contracting lsignatuore <br /> k employ any person <br /> certifies the following: u certify ter as the performance t' the work for whichcomp this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appl- mus all for all required ction Compl drawing on reverse side. <br /> r D. <br /> �- Title: <br /> Signed X <br /> I FOR DEPARTMENT USE ONLY �� Q <br /> Date Area <br /> Application Accepted by <br /> _ <br /> Date Final Inspection by <br /> Date <br /> Pit or Grout inspection by <br /> —�- <br /> 1 <br /> Additional Comments: <br /> El Stk 466-&781 ❑ Lath 969-3621 D Manteca 823-7104 ❑ Tracy 835=6365 <br /> lth Permit/Services 1601 E. Hazelton Ave., P.O. Box <br /> Applicant- Return all copies to: Erivlronmental Hea2009, Stk., CA 95201 <br /> CK RECEIVED 9Y' DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH �]Q <br /> INFO <br /> +.1:H 13-24 IREV.I/ s1 3 S <br /> EH 14-28 <br />