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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> Application is he+eby made to the San Joaquin Local He It 549 for sewage or h District for a PeINo 1862 for Well/pump and the Rules and rR gulations of the San. This Joaquin <br /> 4 <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> Cr city,4 <br /> Lot Size PM <br /> Job Addre <br /> Phone <br /> Address " <br /> Owner's Name <br /> ' )cense fVo Phone <br /> Ss pESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ <br /> - NEW_WEL EOTHER ❑- <br /> TYPE OF WELL/PU P: -'"r'" STEM REPAIR ❑ <br /> PUMPIN TS ALLATION Cl DISPOSAL FLD. PROP. LINE <br /> SEWER LINES �� PITSISUMPS <br /> DISTANCE-TO NEAREST: SEPTIC TANK —��t AGRICULTURE WELL OTHER WELL <br /> FOUL 'D 10N <br /> 4 INTENDED USE TYPE OF WELL _' PROBL, M AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> P <br /> Industrial of Casing <br /> � LI Type . <br /> p Domestic/Private O Gravel Pack Type of Grout <br /> --- <br /> Domestic/ <br /> , .. 1r <br /> Ci Delta Depth of Grout Seal' <br /> t ST Public Surface Seal Installed by <br /> l I Irrigation _..APProx• Depth I 1 Eastern H.P. State Woi*k•Done — <br /> Repair Work Done Typeof Pump Sealing Material Itvp ' <br /> Wei(Destruction O Well Diameter Filler Material IBel 50'1 <br /> pepth �{ <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: N>=W INSTALLATION I'i REPAIR/AUDITION ! DESTRUCTION I 1 INo septic system permitted it pubic sewer is <br /> ' �- <br /> lnstaliation will serve: Residence Commercial— Other <br /> Number of bedrooms Water table depth <br /> h Number of living units: � <br /> ' Character of soil to a depth of 3 feet: CapacitY� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.❑ Foundation Property-Line <br /> Distance to nearest: Well <br /> otal length/size <br /> LEACHING LINE ❑ Na. &Length of fines PropertyLine— <br /> FILTER BED <br /> ❑ Distance to nearest: Wel '" Foundation --- <br /> Number <br /> f � 1 I Depth• Size <br /> rr SEEPAGE PITS Foundation Property Line <br /> I <br /> SUMPS ❑ Qistarice�to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> ! 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 /> I rules and regulations of the San Joaquin Local Health D-istrict, <br /> g that in the <br /> shall not <br /> Home owner or licensed agent's gas torbecame subject Ito workman's coympensation lawsoof California." Contractor's lhir ng or sub-cothis permit isntract nglsignature. <br /> r� employ any person in such manner <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 compere - <br /> tion laws ofCalifornia." ide. <br /> The applicant ust for req i ctions. Comp) a awing mer o r E Date: 66 <br /> + i <br /> Title: <br /> Signed xr <br /> 11 FOR DEPARTMENT USE ONLY <br /> lj7 <br /> f. � r` U Area <br /> Date f <br /> i Application Accepted by X <br /> pate <br /> Pit or Grout Inspection by <br /> Date��— Final inspection by <br /> k � 1 (7 �.) 56385 <br /> Additional Comments: ❑ Lodi 369.3621 Manteca 823-7104 El Tracy <br /> I ❑ Stk 466-6781 <br /> nvironmentaY Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2f)09, Stk., CA <br /> Applicant - Return all copies to: E <br /> CK -.RECEIVED.13Y --� DATE - PERMIT'NO. <br /> FEE _ AMOUNT-DUE AMOUNT REMITTED - CASH"` (� (� <br /> '�•' )NFO <br /> a.EH 13-24 1REV. i n sl /�� <br /> EH 14-28 <br />