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e CO- <br /> APPLICATION <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �, c#AVE., <br /> + <br /> 1601 E. HAZE 1 ON AVE., STOCKTON, CA <br /> Telephone (20g) 466-6781 . <br /> PERMIT EXPIRES 1-YEAR-FROM DATE ISSUED ' <br /> (Complete in'Tripkate) ibed. This appcation is <br /> t <br /> Application is hereby made to the SaCJ iquin Local Healthounty Ordinance No.549 for sewage or /orrNo. 1862 forcwell/pump and the Ryles and herein <br /> Regulations of he San Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District. y <br /> f r�` <br /> '_<XA _ Lot Size r �PM <br /> Job Address <br /> `I' City ,. <br /> Phone <br /> �. (�, <br /> Owner's Name Address <br /> Contractor <br /> �} t not CJ License'No. Phone <br /> Address <br /> NEW WELL ❑ WELL REPLACEMENT <br /> OFWELLIPU ❑ DESTRUCTION ❑ )c � "j <br /> TYPE MP: SYSTEM REPAIR Q OTHER ° �✓�r+� - !J <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. PROP. LINE <br /> SEWER LINES• �� <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications, <br /> ❑ Tracy Type of Casing <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout <br /> Q Other ❑ Delta <br /> El Public Surface Seal Installed by <br /> [7 Irrigation —JApprox4Depth [:3 Eastern H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump �r - Sealing Material {top 50'1—� <br /> Well Destruction qQ Well Diameter <br /> Depth Filler Material (Below 50') <br /> available within 200 feet.) <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADD1TlON D DESTRUCTION -71SNo septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity— No. Compartments <br /> k SEPTIC TANK ❑ Type/Mfg Method of Disposal - <br /> 1 PKG. TREATMENT PLT. ❑ 1 Foundation Property.Line <br /> Distance to nearest: Well <br /> Total length/size " <br /> ' LEACHING LINE ❑ No. & Length of lines <br /> a FILTER SED 1-1Distanceto nearest: Well <br /> Foundation Property Line <br /> r Size Number <br /> SEEPAGE PITS r ❑ Depth Property Line <br /> SUMPS <br /> [I Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> cordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that I have prepared this application and that the work will be done in ac <br /> rules and regulations of the San Joaquin Local Health District. rtify that in the g <br /> �- Home owner or licensed agentnne9as torbecome subjectto workman's compensation laewsoof Californ a." Contractor's lhui gr or sub-cos permit'isnt act nglsignatushall ore <br /> employ any person in such ma <br /> l sa <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 compen <br /> { tion laws of California." <br /> � The appliGpff—MV call for a6 required inspections. Complete drawing on reverse side. <br /> !/!ee T Date: — <br /> Title r <br /> Signed <br /> I OR EP T USE ONLY --� <br /> 1 Date a <br /> ! Application Accepted by' Date Final Inspection by Date �S <br /> Pit or Grout Inspec. n <br /> r <br /> Additional Commen <br /> ❑ Stk 466-8781 Lodi 369-3621 ❑ Mani 823-7104 ❑ Tr y 83 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> } RECEIVED BY DATE PERMIT NO- <br /> FEE AMOUNT'DUE AMOUNT REMITTED CASH <br /> . INFO 04t—Jp37 i/y� S�0� <br /> + EH 13-24(REV.1/557 - . <br /> EH W26 <br />