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_ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA / 333 <br /> Telephone (209) 4L 6 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED d <br /> (Complete in Triplicate) <br /> 1 . <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> 549 for sewage or No. 1862 for weiilpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. <br /> Local F(ealth District. { <br /> A. 1 City Lot Size PM <br /> Job Address i <br /> ,� <br /> Address i Phone-� <br /> Owner's Name - C?5 <br /> .a1`ti--� C o icense No. <br /> Contractor Phone�0 r <br /> Address 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> wPUMP-INSTALLATION`❑"�--SYSTEM <br /> .SYSTEM REPAIR❑ HER-171 <br /> SEWER LINESDISPOSAL FLD. PROP. LINE <br /> 'DISTANCE TO NEAREST: SEPTIC TANK ;� OTHER`WEL ���5'/'SUMPS <br /> FOUNDATION �-AGR1Cl1LTUR`E-WFEI <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia.=of Well Casing <br /> T e of Casing Specifications <br /> ❑ Domestic/Private ❑ Gra%id,Pa�� ❑ Tracy yp g Type of Grout--. - <br /> FI Public [I Other' . ❑ Delta Depth of Grout Seal <br /> I 1 Irrigation _'Approz'Depth. --1 I Eastern Surface Seal Installed by ( , <br /> I H P State Work Done <br /> Repair Work Done [IType-of-Pump - ^ - <br /> '`" Sealing Material (top 50'} W <br /> Well Destruction, ❑ Well Diameter. „ <br /> Depth i _ Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'REPAIR/ADDITION l 1 DE5TRUCTIO gva IablINo erw thin.20system 0 feet.) if public'sewer is <br /> 't ' <br /> Installation will serve: Residence 1. ,Commercial_ Other <br /> Number of living units: Number of bedrooms Wa abl depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ :Type/Mfg <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , . .._ ,,r ; <br /> Di tae io nearest:-""'Wekl�- F_60n05tion Property Line 'f` <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> Pro ert Line 1 <br /> FILTER BED El Distance'Ito,nearestWell Foundation P Y <br /> SEEPAGE PITS t I Depth I Size f — Number <br /> ❑ Distance,to nearest, . eller- Foundation Property Line } <br /> SUMP'S.�f-, ++ . <br /> DISPOSAL PONDS ❑ 1 <br /> f hereby certify that I have prepared tliis application and that the work will be.done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San 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 rhhich 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 /> Y" <br /> tion Yaws of California." _ ', <br /> The app icant call for all equired ins ction Complete drawing on reverse side. d <br /> Signe Title: <br /> FOR DEPARTMENT USE ONLY <br /> F <br /> { 1 � <br /> Area <br /> Application Accepted by Date <br /> f <br /> IFinal Inspection by Date Date f <br /> Pit or Grout lnspectio �w <br /> r q 1 <br /> r <br /> Additional Comments: <br /> .❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-71104` _ O Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E.'Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> I <br /> +� FEE I AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t <br /> . EH 13 24 1/95) <br /> EH 14-26 <br />