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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E...HAZEL T ON AVE., STOCKTON, CA y <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Pp ' <br /> made a compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welklpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. 1 � <br /> r <br /> City Lot Size PM <br /> Job Addressw! <br /> r / Phone <br /> Owner's Nameel6�Bl� Address <br /> f ; License No. Q 6—Phone <br /> Contractor L Address L REPLADESTRUCTION CI <br /> NEW WELL C] WELC <br /> EMENT El <br /> TYPE OF WELL/PUMP: STEIVI�REPAIR L]"'"""' "' OTHER ❑ " <br />" - -� PUMP INSTALLATION-0---Sy t <br /> i ...DISTANCE TO NEAREST:,SEPTAMC-- ER LINES- - <br /> ---SEW ,-1� DISPOSAL FLD. PROP. LINE <br /> TIC <br /> FOUNDATION AGRICULTURE WELL - OTHER IN£LL' PITSISUMPScf <br /> INTENDED USE TYPE OF WELL PROBLEM AREA -'CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial -" - Specifications <br /> Type of Casing <br /> ❑ Domestic/Private L3 Gravel Pa, ❑ Tracy Depth of Grout Seal Type of Grout - <br /> i"1 Public.t 1-! Other 1 CI Delta <br /> Approx. Depth l l Eastern Surface Seal InstaNed by <br /> I 1 Irrigation i , State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction I:) Well Diameter Sealing.Material(top-50') <br /> 4 r Filler Material IBelow 50'1 <br /> I Depth <br /> ` TYPE OF, SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/.ADDITION l 3 DESTRUCTION alvailable1w thin 200 feet.ied it public sewer is <br /> Installation will serve: Residence — Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ! Property Line <br /> Distance to nearest: Well Foundation P Y <br /> l i <br /> F LEACHING LINE D No. & Length of lines Total lengthlsize— <br /> ty <br /> ❑ Distance Property Line <br /> e to nearest: Well Foundation f' <br /> � <br /> FILTER BED 1 <br /> r <br /> Number <br /> SEEPAGE PITS I I Depth } $1Ze Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> i DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> i "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> l 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 /> 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." yl <br /> The appli nt ust ca f t c' ns. Complete drawing on reverse side. 9� <br /> Signed x II r i <br /> Title: � - Date: <br /> RTNIENT USE ONLY <br /> I 2 5 AV Area <br /> Date <br /> Application Accepted by F Gr-ra irLua•+ <br /> r F Date Final Inspection by r w "r Date <br /> i Pit or Grout Inspection by 1I D v s Lel <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3 621 ❑ 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 /> FEE CK It RECEIVED BY DATE PERMIT NO. <br /> EEINFAMOUNT DUE AMOUNT REMITTED CASH <br /> +.EH 1324IREV.�iH51 Y-S, - �� <br /> } <br /> EN 14-26 <br />