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APPLICATION FOR PERMIT J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> bad This all <br /> work herein <br /> 10 <br /> av <br /> madecalf "is <br /> Applicationcompliance <br /> lance with <br /> Sano the Joaquin nJoaquin Local He Ith County ordinance No.District549 for sewage or It to No. 1662 forcwe 1/dpump atnd the Rules and Regd u ations of the San Joaquin <br /> made in co p <br /> Local Health District. ,. <br /> E o H .dT '`Q!' City .�.8i d �- Lot Size PM <br /> c�CPM 5 �1 <br /> Job Address [/ I <br /> Address <br /> J/ F � ° Phone 7 f 7 <br /> k Owner's Name �r <br /> p ^���� �–Phone <br /> Contractor <br /> iIJ�C�I Address � g? r �`� cense No. NY <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> ❑ <br /> SYSTEM REPAIR ❑ l�Fl� ROP LINE4� <br /> PUMP INSTALLATION Q �,�ER <br /> DISTANCE TO NEAREST: SEPTIC TANK P SEWER LINES <br /> .� DISPOSAL FLD. <br /> FOUNDATION __10 AGRICULTURE WELL —� OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Industrial Open Bottom ❑ Manteca Die, of Well Excavation Specifications <br /> k Type of Casing ``}}( <br /> kDomestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Grout <br /> ❑`Public ❑ Other ❑ Delta Depth of Grout Seal T� <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Workbone [-IType of Pump <br /> f Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlailableo Sept wth ne200 permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> a Character of soil to a depth of 3 feet: <br /> (, No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> " Method of Disposal <br /> i PKG. TREATMENT PLT, ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> I <br /> - Total length/size <br /> LEACHING LINE ElNo. & Length of lines Property Line <br /> FILTER BED L] Distance to nearest: Well Foundation <br /> i { Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> SUMPS 11 Distance to nearest: Well Foundation <br /> 1 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> E rules and regulations of the San Joaquin Local Health District. <br /> i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which ng permit is issued, I shall not <br /> "Contractor's hiring <br /> employ any person in such manner as to become subject to workman's compensation laws of California. permit <br /> sub-contracting signature <br /> 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 /> The applicant must `1/#or iced 'nspectio plete drawing on reverse side. 3 �I 7 <br /> Signed <br /> Title: <br /> Date: — <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> 2— <br /> Date—T. <br /> Application Accepted by <br /> Date <br /> r �-^ <br /> Pit or Grout Inspection IJ Date <br /> �` Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466.6781 [-1Lodi369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 p85 <br /> nmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA <br /> Applicant- Return all copies to: Enviro95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO - --,raZ <br /> + EH 1324(REV.I/85) <br /> EH 1428 <br />