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APPLICATION FOR PERMIT ` <br /> SAN <br /> ,1OAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL.1ON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> k (Complete in Triplicate) application is <br /> r <br /> is he+uy No.549 for sewage or No. 1862 for well!pump and the Rules and Regulations of the San Joaquin <br /> Application made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. of Size PM -- <br /> F } <br /> l City <br /> Job Address i '551 5 �. Phone <br /> r '` ,��.rt]]tt.... ^�, Address- h, <br /> Owner's Name ` ` Phone <br /> License No. -�-- <br /> � ��� Address DESTRUCTION <br /> ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> NEW WELL ❑ OTHER ❑ <br /> I TYPE TDF TALLATION El SYSTEM REPAIR ❑DISPOSAL FLD. PROP. LINE <br /> PUM % <br /> i SEWER LINES .�—•— PITSISUMPS �— <br /> DISTANCE TO NEAREST: SEPTIC ITA AGRICULTURE WELL <br /> FOUNDATION <br /> OTHER WELL <br /> TYPE OF WELL PROBLE A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> I INTENDED USE ❑ Manteca of Well Excavation Specifications <br /> ❑ Open,Bottom <br /> ❑ industrial ❑ Tracy Type o sing <br /> ❑ Domestic/Private ❑ Gravel'.Pack Type of Grout �--' <br /> i'1 Public Cl other s <br /> n Delta Depth of Grou eal <br /> Surface Sea, Installs ` r <br /> t. I I irrigation' __Adprox. Depth t 1 Eastern Sta Work Done— �J <br /> H.P. <br /> i Repair Work Done ❑ Type of.Pump Sealing Material (top 50'1 <br /> Weil Destruction [-IWellDiameter �-— Filler Material iBelow 50'1 <br /> Depth No septic <br /> system permitted if public sewer is <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WDflK: NEW INSTALLATION I.I REPAIR/ADDITION l 1 pESTRUCTId p <br /> Commercial— Other <br /> Installation will serve: Residence— <br /> 'Number of bedrooms Water-table depth <br /> Number of living units: <br /> Character of sail to a depth of 3 ents <br /> 'feet: Capacity_�— <br /> No. Compartm ' < <br /> I SEPTIC TANK [3 Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation�—-Property Line <br /> Distance to nearest: Well <br /> I. Total lengthlsize <br /> Length of lines <br /> LEACHING LINE 0 N6!&. Well Foundation_—�— property Line <br /> FILTER BED ❑ Distance to nearest: <br /> L l h <br /> Number <br /> DeptSize <br /> SEEPAGE PITS Foundation Property Line <br /> L) Distance to nearest: Well' <br /> 5UMP5 state laws, and <br /> -- <br /> DISPOSAL PONDS ❑ <br /> ' aied this application and that the work will be done in accordance with San Joaquin county ordinances, <br /> I hereby certify that I have prep. <br /> shalt not <br /> rules and regulations of the San;Joaquin Local Health Dietrict.g' <br /> Home owner or licensed agent's signatures pig Subjacthe �Ito workman'srtcoympensation I.that in the sews of California." Contract work for is+hiri hiring or sub-cont actngt is issued, lsgnature <br /> employ any person in such manner a5 to b <br /> certifies the following: "I certify <br /> lion <br /> in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." A <br /> The app 1c.nt Must call for all required inspections Complete drawing on reverse�si <br /> �.� d Title: 6/F11i[/ pate:I Int <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> 1 Date Area <br /> Application Accepted by V` Date t <br /> .Date -�— at Insppcti n by <br /> Pit or Grout Inspection by r <br /> Additional Comments: ❑ Manteca 823 7144 ❑ Tracy 835-6395 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton.Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH <br /> ' INFO .i f <br /> ♦.EH13-24WEV.1/95) f <br /> EH 14.28 <br />