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4 <br /> r< �- APPLICATION. FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ��" f <br /> Telephone 12091 466-67$ = <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> y 3 , . <br /> (Complete in Triplicate) lication is <br /> Health District for a permit to construct and/or install the work herein desc <br /> Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Heribed. s app <br /> made in compliance with San_Joaquin County <br /> Local Health District. <br /> PM s <br /> City r Lot Size {moi r <br /> Job Address <br /> ff Address •�C Phone- , <br /> Owner's Name Phone <br /> ! License No. <br /> ' Address <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> NEW WELL ❑ <br /> TYPE OF WELLIPUM � � SYSTEM REPAIR ❑ OTHER El <br /> PUMP INSTALLATION ❑ DISPOSAL FLD PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC SEWER LINES NK—" TURE WELL OTHER WELL PITSISUMPS <br /> FOUNDATION CATIONS <br /> T <br /> INTENDED USE TYPE OF WELL PROBLEM ARE pia. of Well Casing <br /> ❑ Open Bottom nteca Dia. of Well Excavation Specs _ S <br /> ❑ industrial I O Tracy Type of Casing <br /> ❑ Domestic/Pri to ❑_:Gr c Type of Grout <br /> Other ❑ Delta Depth of Grout Seal <br /> ❑ Public Surface Seal Installed by <br /> EJ irrigation ___}Approx. Depth ElEastern H.P. State Work Done <br /> _� <br /> Repair Work Done EJ Type of Pump Sealing Material flop 50'i <br /> -Well Destruction ❑ Well Diameter <br /> Filler Material (Below 501 <br /> Depth, <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ftEPA1RIADDITION ❑ DESTRUCTION No septic system permitted if public sewer is <br /> r�� <br /> Installation will serve: Residence, Commercial, Othek � T <br /> Number of living units: � <br /> Number of bedrooms Water table depth <br /> .. <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments �1 <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ i Foundation ° Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> Y LEACHING LINE ❑ No. & Length of lines Foundation - Property Line �» <br /> FILTER BED .�., -.«- ❑ -Distance to nearest: Well <br /> - P <br /> l <br /> ? � Number <br /> ❑ Depth Size <br /> SEEPAGE PITS Foundation Property tine -- <br /> SUMPS El . Distance to nearest: Well - <br /> 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 District. I cart that in the performance of the work for which this permit is issued, l shall not <br /> signal e <br /> Home owner or licensed agent's signature certifies the fallowing: " of California." Contractor's <br /> employ any person in such rmanner <br /> as to n the become <br /> omperfoe subject <br /> ance of the work for which h compensation per <br /> is issued,I shall employ persons rsubject t workman'ring or sub- o as eompensa- <br /> certifies the following:'I certify <br /> tion laws of California <br /> ired inspections. Complete drawing on revers side. <br /> The appricant must call for all requDate: <br /> Title: <br /> Signed X <br /> F DEPARTMENT USE NLY <br /> fnlvv�\ Date Area <br /> Application Accepted by Date <br /> f - Date Final Inspection by <br /> Pit or Grout Inspection by <br /> x Additional Comments: ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 0 Lodi 369-36210.Manteca 823 7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2 Stk., C 1 <br /> r CK RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> " r INFO <br /> It '+EH 13=24 1Rrvi-i <br /> EH 14-28 <br />