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APPLICATION FOR PERMIT <br /> i. SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA RECEIVED <br /> Telephone (209) 466-6781 <br /> ' PERMIT EXPIRES 1YEAR FROM DATE ISSUED AUG 11988 <br /> (Complete in Triplicate) <br /> E 94A� ad � pppb plication is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install l��I �an Joaquin <br /> made in compliance with San Joaquin County Ordinanc No. 549 for sewage or No. 1862 for well/pump and the RrrleAai <br /> Local Health District. .3 � floss4ale , <br /> Cit Lot Size PM <br /> -Job Address- <br /> Address Phone <br /> Owner's Name • <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION elf e� <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ©Wlr64 <br /> TOLI <br /> DISTANCE.TO NEAREST:..SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL t PITSlSUMPS <br /> .INTENDED USE TYPE OF WELL PROBLEM AREA-; CONSTRUCTION SPECIFICATIONS a pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca f�$Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> T Specifications <br /> f"i Public <br /> t l Other Cl Delta Depth of Grout Seal Type of Grout <br /> ,� <br /> I I Irrigation _,.Approx. Depth t,) Eastern Surface Seal install d by <br /> Repair Work Done ❑ Type of Pump 4 <br /> H State Work Done <br /> P, _ <br /> Well Destruction [-IWellDiameter x Sealing Material (top 50'1 <br /> l Depth s k Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION 1J REPAIR/ADDITION i I DESTRUCTION I I (No septicailabla system <br /> m feet.) if public sewer is <br /> 4 Installation will serve: Residence_ Commercial_ Other <br /> Number of living units:: Number of drooms <br /> .� Water table depth <br /> Character of soil to'a-depth of 3 feet: <br /> w SEPTIC TANK ❑ Type/Mfg i pacity No. Compartments <br /> �. PKG. TREATMENT PLT. ❑ <br /> F Method of Disposal <br /> I a` Distance to nearest: Well Foundation Property Line <br /> 1 E <br /> LEACHING LINE ❑ No. & Length of I' �'Total length/size, <br /> FILTER BED t❑ Distance to arest: Well oundation Property Line <br /> SEEPAGE PITS l I.. pth " <br /> ____L_Size <br /> Number <br /> iSUMPS Li ce to nearest: Well } Foundation Property-Line <br /> F <br /> DISPOSAL PONDS '.� , - <br /> I hereby certify that I hav--prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an(V <br /> rules and regulations of the San Joaquin Local Health DWr,ict. t <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 note. _. <br /> E such.,mannar as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature/employ <br /> re <br /> employ any person in <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 /> f tion laws of California." < <br /> The applicant f _ t' a <br /> nt must call for II required inspect' ns. Complete drawing on reverse side. ..� 00 <br /> Title: Date: - <br /> r.; Signed-X <br /> ° FOR DEPARTMENT USE ONLY <br /> i Application Accepted by s ' f `f'P Date / 4 Area / <br /> Pit or Grout Inspection by <br /> Date iFinal Inspection by Date <br /> Additional Comments: _ <br /> ..❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantec 823-7104 ❑ Tracy 835-6385 ` <br /> Applicant Return all copies to: Environmental Health Per it/Services 1601-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> INFE AMOUNT DUE AMOUNT REMITTED w CASH //y <br /> +.EH13-24(KV.iiNsY (� �� / ~'" �� <br /> t EH 14-26 _ �» <br /> i <br />