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! APPLICATION FOR PERMIT Oft" <br /> _ '.. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL' VE., STOCKTON, CA <br /> Telephone (2091 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <br /> permit to construct and/or install the work herein described. This application is <br /> aquin Local Health District fora p <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage omp and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Jor No. 1862 for welllpu <br /> Local Health District. <br /> Cit <br /> C11 t Size PM <br /> Job Address <br /> G � <br /> Phone <br /> dress � <br /> Owner's e <br /> t © <br /> ass Q X License No. 21 phone <br /> ContracDESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION. i�/ <br /> SYSTEM REPAIR ❑ OTHER El <br /> • SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS Well Casing <br /> INTENDED <br /> USE Dia. of g <br /> ❑ Open Bottom ❑ Manteca Dial. of Well Excavation <br /> LJ Industrial Specifications — <br /> ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑'Domestic!Private Type of Grout <br /> i ublic <br /> I i Other # <br /> [I Delta Depth of Grout Seal <br /> I Irrigation _.Approx�Depth l I E stern Surface c^2Installed by <br /> Type of Pump H.P. <br /> State Work Done <br /> Repair Work Done <br /> Well Destruction F] Well Diameter <br /> Sealing Material Itop 501 <br /> Depth J Filler Material (Below 501set ! ., <br /> TYPE OF SEPTIC WORK: NEW:INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION l I aNailabperwithin 200 feetrt�ed it public sewer is W <br /> Installation will serve: Residen e�� Commercial Other-��--- <br /> Number of living units: l� Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ i I <br /> Distancelto nearest: Well Foundation Property Line <br /> fTotal length/size <br /> YYYY LEACHING LINE ❑ No, & Length of lines <br /> FILTER BED D Distance to nearest: Well <br /> Foundation Property Line <br /> a Size _ Number <br /> SEEPAGE PITS I l Depth Foundation Property Line <br /> i SUMPS i_1 Distance to nearest: i Well <br /> DISPOSAL PONDS ❑ <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this app <br /> rules and regulati the San Joaquin Local Health District. work for <br /> Homo oawne arson insuchntnrie9as tore certifies <br /> come suhgctlto wlorkman'srtify that in the compensation Iawsoof�Californiahe Contract which <br /> hiring or sub contraeirnglsignatushall ae <br /> am310,y <br /> y P permit is issued, I shall employ persons-subject to workman's compensa <br /> ce 310,ifie he following: that in r ce f the work for which <br /> tion la s of California." <br /> The a plicant mu I i all req r <br /> Co I to drawing re e rde. <br /> 90"Pt� /Date: <br /> I. Title: <br /> Signed <br /> 1. F RTMENT USE ONLY 1 <br /> Area <br /> Pit or Grout Inspection by Date 1 <br /> Application Accepted by <br /> li Final inspection 6y" Date I C fv <br /> l <br /> a <br /> Additional Comments: <br /> Stk 466-6781 O Lodi 369-3621 0 Manteca 823 7104 . Tracy 835 6365 <br /> EJ Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95401 <br /> CK RECEIVED By DATE PERMIT•NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> s EM13-241REV.t/n51 <br /> N 14.28 -'- <br />