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L APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 " <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> s € (Complete in Triplicate) ` <br /> permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District foraRegulations <br /> -d <br /> made in compliance with San Joaquin County Ordinance No.549 for.sewage or No.1862 for well/pump and the Rules and R�Mations of the n Joaquin <br /> Local Health District. �� p <br /> ©2- /ill z t�.�Z City Lot Size O PM <br /> r Job Address ` 5- S A? <br /> i C <br /> �4VL Phone ' <br /> 0 :k Address <br /> Owner's Name "' Y <br /> Phone <br /> License No. a- <br /> Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: { INEW WELL 11 OTHER ❑ <br /> PUMP INSTALLATIbN�] SYSTEM REPAIR ❑ <br /> s �' 'SEWER LINES DISPOSAL FLD. PROP. LINE ^ <br /> DISTANCE TO NEAREST: SEPTIC TANK— OTHER WELL PITS/SUMPS <br /> FOUNDATION- f AGRICULTURE WELL <br /> 9 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing <br /> s <br /> El Industrial O Open Bottom an 03 Dia. of Well Excavation <br /> 0 Tracy Type of Casing Specifics ions <br /> ❑ Domestic/Private n Gravel Pack _ ❑Delta"" "DBPth of"Grout Seal'- Type of Grout <br /> 11 Public L1 Other <br /> 11 Irrigation � P-l?7x• De pth ❑ Eastern Surface Seat Installed by ( , <br /> l '" t 3 V1 H.P. StSte Work Done <br /> Repair Work Done L1 Type of Pump I <br /> Well Destruction El Well biameter <br /> Well <br /> Material (top 501 <br /> Depth 1 Filler Material IBelow 501 perm <br /> TYPE OF SEPTIC WORK: ,NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septi system <br /> te200 feetitted if public sewer is <br /> Installation will serve: Residaince_�[�CfOrnmercial Other <br /> e <br /> Number of living units: �' Number;of bedrooms ! <br /> /L/� Water table depth <br /> Character of soil to depth fof 3 feet-::,-- ._ a city 4 No• Compartments <br /> 1 SEPTIC TANK ❑ ?ypeIMfg' f. <br /> Method of Disposal <br /> PKG. TREATMENT PLT-_,E3 ,t z i �✓ <br /> Foundation Property Line <br /> f` Distance o leii+est:.: ell• <br /> c <br /> LEACHING LINE XINo. & Length of lines <br /> f i Total length/size i ^ <br /> n� .. .- .�`"' Foundation �� , I Property Line <br /> FILTER BED ❑ IDistance to nq est: Well <br /> Dept 5 Size :,. �' Lumbar � <br /> SEEPAGE PITS i r i Property Line <br /> SUMPS LJ r Distance to nearest: Well (�1— Foundation P rtY <br /> { # r <br /> DISPOSAL PONDS ❑ 1 <br /> 1 hereby certify that I have prepared this application and that the work will be dOrre in accordance with San Joaquin county ordinances, state laws,and <br /> rules and regulations of the jSan Joaquin Local Health District. \ <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 signature <br /> shall not <br /> Of Califor <br /> employ any person in such manner as o become subject to workman he work for wh ch this tperm iion t issued I shall employ persons nia." Contractor's lsubj ct o workman'ring or s sub-contracting <br /> the following: "I certify _ performance <br /> tion laws of Ca'fornia." "irle <br /> The appti t st,c forall it inspe ions. Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> Signed r <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> r Date <br /> Application Accepted by k^ r Date�� � <br /> , " 1 - `U Final Inspection by <br /> I" <br /> Pit or Grout Inspection by- Date <br /> Additional Comments:- - "F" `! <br /> ❑ Stk 466-Ml ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O• Box 2009 1 � <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH'73.24(REV.10183) /40, <br /> EH`14-26 <br />