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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> ! Telephone (209) 466-6781 <br /> [PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein <br /> . This <br /> cation <br /> is <br /> made in ApplicationisNance writtade h Sano the San Joaqu n County Ordnance Nuin Local th District for a o. 549 for sewage or permit <br /> No. 1862 for wel�pump and the Runes and Regulations of the San Joaquin <br /> made in compliance <br /> Local Health District. <br /> City S Lot Size <br /> PM <br /> Job Address <br /> /(fa�� Address Phone <br /> Owner's Name — ^ <br />— - _^Contraetgr _ - Address , - <br /> ` License No Phone <br /> ' JHTYPE Of WELL/PUMP: i NEW WELL ❑� WELL REPLACEMENT ❑ DESTRUCTION LJ' x4 PUMP INSTALLATIQN F7SYSTEM'REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER_L1NES__. — _ DISPOSAL FLD. PROP. LINE <br /> ? FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREiA-"-_,'CONSTRUCTION SPECIFICATIONS pia. of Wel Casing <br /> Ll Industrial ❑#Open Bottom -0 Manteca Dia. of Well Excavation % J <br /> Type of Casin M1 Specifications <br /> ❑ Domestic/Private a ❑:Gravel Pack ❑ Tracy YP g Type of Grout--- <br /> ❑ Other r Delta Depth 'Grout Sealt <br /> I'l Public. <br /> I I'riigation -Approx. Depth l I Eastern �Y,., Surface�Seal Installed by <br /> State,,,Work,Roiae _ <br /> Repair Work Done 0 ! Type of Pump " IA, Sealing <br /> H P''. L <br /> Well Destrrlction L) } Well Diameter Sealing Md,terial )top-60'I <br /> r { pepth Filler Material (Below 50'4, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I,;;REPA1NIRI,ADP1TI( .DESTRUCTION i I (No septic system <br /> m rented if public sewer is <br /> f <br /> ava <br /> A.`':„ Installation will serve: Residence! Commercial Oiher j <br /> �.� i e <br /> 4' Number�of living units: .__ Number o#.bedrbems_�-- <br /> Water-table depth <br /> Character of soil to a depth of 3 feet: <br /> tC7 .Type/Mf ! Capacity No- Compartments <br /> l SEPTIC TANK g =!I"� �. — <br /> Method of Disposal <br /> PKG. TREATMENT PLT. F41 _ A,tw-. C� °r'� ; 9' <br /> _ Distance to nearestWell,�.--T Foundation� Property Line <br /> !' <br /> rci <br /> Total tlength/size <br /> LEACHING"LINE 'No. & Length of lines <br /> FILTER BED ❑ Distance'ta-nearest'- Well Foundation_ 22- Property� Line — <br /> ; a <br /> SEEPAGE PITS' 44 !Depth ` 2 Size Number <br /> r <br /> Property <br /> LineWeSUMPS L D1stante to nearest: Foundation <br /> - <br /> I DISPOSAL PONDS ❑ - ;= { 9 <br /> I hereby certify that I have preparetifthis applicatior'r and'that-the work wil! be done in accordance with San Joaquin.county ordinances, state laws, and <br /> rules and regulations of the San Joagyjin Local Health Di§trict. shall not <br /> := <br />! Home owner or licensed agent's signa{ure.certifies the following: "I certify that in the performance of the work for which this permit is issued, I <br />+ signature <br /> employ any person in such manner as to'- subject to workman's compensation laws of California." Contracersonshiring <br /> subiect to workman's sub-contracting <br /> the following: "I certify that in the performance of the work for which this permit is issued, I shat employ p <br /> tion laws of-California." ( ` <br /> } <br /> The applicant must call for all quired inspections. Complete drawing on reverse side. <br /> .c Iii, <br /> Da <br /> Title: te: <br /> Signed X = - <br /> r <br /> ONLY <br /> USE O <br /> FOR,DEPARTMENT Nr <br /> : . ..�1.,. <br /> m- .s.- / Area <br /> Application Accepted by! <br /> pate <br /> iDate Final Inspection byt Date <br /> Pit or Grout Inspection by <br /> Additional Comments: € <br /> 0 Stk 466-6781 n Lodi 369-3621 Q Manteca 623-7104 ❑ Tracy 1335-6385] <br /> Applicant; Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> e FEE AMOUNT DUE AMOUNT REMITTED - CK RECEIVER 6Y DATE PERMIT'NO. <br /> INFO I CASH <br /> Q <br /> +.EH 13-24 IREV.1/N 5) Z <br /> EH 14-26 <br />