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' o ii <br /> j APPLICATION FOR PERMIT / -�- �—�.' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _4 Uh <br /> 1601 E. HAZELTON AVE., STOCKTON, CA L� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ii (Complete in Triplicate) ribe -�1'[ <br /> San Joaquin Local Health District for a permit to construct and/or install the works and herein <br /> Re Regulations of the Sa.This n Joaquin <br /> on is <br /> Application i,fiance made to the q <br /> made tri combfiance with San Jo quip County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rue 9 <br /> Local Health District)n—x <br /> City Lot Size PM <br /> ✓� <br /> Job Address ( � �}SPhone <br /> t ` 4,13 �-- Address _ <br /> Owner's Naive a , <br /> ti /J1_ Y l License No. Phone <br /> ontractor �! Address <br /> TYPE OF WELL/PUMP: NEW WELL LJWELL REPLACEMENT 11DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ .SYSTEM REPAIR ❑ OTHER ❑ <br /> II DIS AL FLD. PROP. LINE <br /> ( DISTANCEfTO NEAREST: SEPTIC TANK SEWER LINES-_, <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE F WELL PROBLEM AREA CON CTION SPECIFICATIONS <br /> ❑ Industrial D.-Open Bottom <br /> Ea. of Well Excavation <br /> Dia. of Well Casing <br /> Manteca <br /> d Trac Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack # Type of Grout <br /> I CI Other ..t A - Delta s +, Dept ut Seal YP <br /> M Public i� 1 ,. <br /> I I Irrigation) _.A H. <br /> t i Eastern Surface Seal Insta <br /> e of 7 H.P.''. State one — <br /> Repair Work Done ❑ pPump. <br /> Well Destruction ❑ Well Diameter " y'Sealing Material (top 50"1, <br /> Depth Filler Material (Below 501 <br /> TYPE of: SEPTIC WORK: NEW INSTALLATION I:i REPAIRIADDITION l I DESTRUCTION available within 200 fe tif public sewer is <br /> permitted(No septic system <br /> 4 <br /> _ _,. " <br /> Installation will serve: Residence Commercial Other <br /> h r <br /> Number:nf living units: Number of bedrooms V Water table depth <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK Li�d Type/Mfg <br /> i <br /> capacity— <br /> SEPTIC <br /> Compartments <br /> �I� Method of Disposal <br /> PKG. TREATMENT PLT. ❑! <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of fines <br /> Total length/size <br /> FILTER BED ❑. Distance to nearest: Well Foundation Property Line <br /> SEEPAGE�PITS I 1 Depth Size Number <br /> y SUMPS i Ll+ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑. <br /> Thereby certify that I have p ,repared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsan <br /> Id <br /> rules and'�regulations of the San Joaquin Local Health District. <br /> ertify that in the performance of the work for which this permit Is issued, f shall not <br /> Home owner or licensed agent's signature certifies the following: "I c �p <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 3 <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws.of California." ��' <br /> The applica ust c tf ior•all required spections. Complete drawing on reverse side. <br /> Oil 4 ["! <br /> ! Title: Date: <br /> Signed <br /> it FOR DEPARTMENT USE ONLY <br /> Date A ea <br /> Application Accepted by <br /> r �I' Date Final Inspection by t Dat <br /> Pit or Grout Inspection by <br /> Additional Comments: r e <br /> ElStk 466-6781 ❑'Lodi 369-3621 [1 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicarit Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2(109, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C <br /> RECEIVED BY DATE PERMIT NO. <br /> i INFO <br /> ♦.EH 13-24 1REW 1115 <br /> £H 14-26 - ' <br />