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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> he work <br /> lication is <br /> Application is hereby made to the San County Local <br /> Health <br /> District <br /> for sewage or rNoo 1862 for we l/construct pump atnd the Rules and IR Regulations of(the Sis an Joaquin <br /> made in compliance w <br /> ith Local Health District. <br /> City <br /> Lot Size PM <br /> Job Address f I Y L <br /> s Address Phone <br /> Owner's Name / �I <br /> Contractor Address <br /> ' r License No.vat-16—Phone <br /> TYPE OF WELL/PUMP: NEW WELL LJ <br /> REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO <br /> SYSTEM REPAIR ❑ OTHER E3N <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -..— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> �-- <br /> ❑ Domestic/Private ❑ Graver Pack LJ Tracy of Casing Tracy Type of Grout--­ <br /> n <br /> rout - <br /> f� Public t=1 Other Cl Delta Depth of Grout Seal <br /> I IrrigationApprox. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. ,�Z State WoI one <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 — <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:! REPAIR/ADDITION LI DESTRUCTION i I (No sbetic system <br /> rmil ed if public sewer is <br /> r � <br /> Installation will serve: Residence_ Commercial— Other O <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: N a Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> A Method of Disposal <br /> PKG. TREATMENT PLT. ❑ '. ' <br /> Distance to nearest: .+ Well` <br /> Foundation Property Line T <br /> Total length/size <br /> 1 LEACHING LINE ❑ No. & Length of lines Property Line <br /> i t . �. <br /> FILTER BED ,- ❑ Distance to nearest: Well Foundation p Y <br /> SEEPAGE PITS l I Depth Size Number <br /> ,� "" Foundation ""° Property`Lirie <br /> SUMPS— _ LI Distance to nearest: 1iVell <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application arid.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 Districts ' ' <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, !shall not <br /> s-ofCalifornia.' Contractor's hiring or sub-contracting signature <br /> employ any peon in such manner as_to_become subject to workman's compensatioritaW <br /> rsworkman' <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 I requi ions. Complete drawing on rev se side. <br /> ��Tit9e: <br /> �Q Date: <br /> Signed X <br /> f FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by - <br /> Pit or Grout Inspection by <br /> Date Final Inspection b Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 TO, <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> RECEIVED By DATE PERMIT N4. <br /> ffBgHX!J!CK <br /> ASH <br /> +.EH 53-24 I HEV.I/H 51 <br /> EK 14-29 <br />