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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELi ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> applicationrk herein described. This is <br /> th District for a <br /> Application <br /> compliance is made to the San <br /> +n County ordinance lHl 549 for sewage or permit <br /> 1862 for construct and/or <br /> and the Rues and Regulations of he San Joaquin <br /> made in <br /> Local Health District. <br /> Q O City S Lot Size PM <br /> Job Address <br /> II{ Phone <br /> ! 5~0q(0 <br /> . __ $ <br /> �f'1lAddress <br /> Owner's Name { <br /> F o- License No. - Phone <br /> Contractor Address <br /> NEW WELL ❑ WELL REPLAGEMENT 11 DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: $ r SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF-WELL PROBLEM ARCONS <br /> EA TRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 1 ❑ Industria! ❑ Open Bottom Li Manteca <br /> Dia. of Well Excavation <br />' r Type of Casing Specifications <br /> ❑ Domestic/Private 0 Gravel Pack ❑ Tracy yp Type of Grout <br /> r it Public Cl Other j 1 1 Delta Depth of Grout Seal <br /> y �_Approx. Depth I I Eastern-, Surfaoe Seal installed by <br /> I I Irrigation '; r^ State Work Done <br /> Repair Work Done ❑ Type of Pump H.P." <br /> Wel! Destruction ❑ Well Diameter <br /> Sealing Materia! (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NFW INSTALLATION I:I REPAIRlADDlTION LI DESTRUCTION <br /> (lvailabseptic <br /> ethin 200 feet.) ifF public sewer is <br /> 3 <br /> I Installation will serve: Residence Commercial,_ Other <br /> i F <br /> Number of living units: Number of bedrooms Water table depth <br /> i Character of soil to a depth of 3 feet: No, Compartments <br /> E SEPTIC TANK El Type/Nlfg Capacity <br /> ��. Y Method of Disposal <br /> LJ1' <br /> PKG. TREATMENT PLT. . , <br /> Distance to nearest: Well Foundation Property Line <br /> { .y, <br /> Total length/size <br /> LEACHING LINE L-1No. &!Length of lines <br /> FILTER BED <br /> ❑ Distance to nearest: well Foundation Property Line <br /> ri <br /> Number <br /> I SEEPAGE PITS I ] Depth' Size Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> certify that will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby I have prepared this application and that the work <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 compensation laws of California." Contractor's hiring or sub-contracting signature <br /> I 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 /> r The appii m t call or quired ins c a mplai drawing on reverse side. B <br /> Signed X <br /> �� ��'�/fitle: _ �►xnn:tJ\ Date: <br /> FOR EPARWENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by � Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 D 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 95201 <br /> CK RECEIVED BY DATE PERMWNO. <br /> FEE OUNT DUE AMOUNT REMITTED SH <br /> INFO <br /> +.EH 43-24(REV.1/95) <br /> r r <br /> EH 14-28 <br />