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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> x Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work herein <br /> Application is <br /> cation is hewith SanoJoaquthe an County Ord naLocal <br /> nce No.549 for sewage or permit <br /> 1862 for cweil/pump end the Rules and Regulations of tthe San is l Joaquin <br /> made'in-compliance <br /> Local Health District.- / <br /> City Lot Size <br /> PM <br /> Job Address - � <br /> ` Phone <br /> Owner's Name F -- 4,� <br /> s ` _ <br /> No Phone <br /> Contractor ress <br /> TYPE OF WE 1PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTR TION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> F DISTANCE.TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications Q <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout — <br /> f ['1 Public C1 Other r Ci Delta Depth of Grout Seal <br /> I I Irrigation — Approx. Depth i I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> ealin ling-Material <br /> Destruction ❑ Well Diameter 9 - <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION l I DESTRUCTION [ I (No septic system permitted if public sewer is \ . <br /> J1 _ <br /> available within'200 feet.) <br /> Installation will serve: Residence�_ Commercial Other' ' <br /> Number of living units: Number of bedrooms _..—�+.' Water table depth <br /> r ' - <br /> Character of soil to a de th of 3 feet: <br /> SEPTIC TANK ❑ Type/#fg <br /> Capacity ® No. Compartments <br /> I Method of Disposal <br /> ' PKG�TREATMENT PLT. ❑ l € , <br /> Distance to nearest: Well, Foun3ation E/ Property.Line— <br /> s <br /> LEACHING LINE ❑ No. &I ength of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: 'Well Foundation Property Line �— <br /> r Size Number <br /> r SEEPAGE PITS l 1 Depth' <br /> SUMPS Ll Distance to nearest: Well 16�" Foundation_!�74— Property Line <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 /> rules and regulations of the San Joaquin Local Health,District. <br /> Home owner or licensed agent's signature certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall not <br /> 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." <br /> The applicant naust call for all req spections. CompI to drawing on reverse j e. <br /> Title: - Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY /I p <br /> Date `( � � p f Area + i <br /> Application Accepted by — I` =Z7 Pit or Grout Inspection by pate Final Inspection by �• DateO <br /> j } <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 -❑ Manteca a23-7104 ❑ 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 RECEIVED BY DATE PERMIT NO. <br /> I INFO-,-- <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> ?OFY <br /> +-EH 13-24 IREV.f n 51 <br /> EH 14-2a <br />