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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT } <br /> S <br /> r 1601 E. HAZEL'+ON AVE., STOCKTON, CA - <br /> ( Teleohone (209) 486-6781 <br /> PERMIT EXPIh S 9 TEAR FROM DATE ISSUED <br /> ..,'i , r. „ ,. (Cornplete in Triplicate) <br /> or <br /> all the work <br /> cation is <br /> Application is hereby mh San J he San Joaquin <br /> n County ordinanHealth ce No.District <br /> for sewage or it to 1862 cfor onstruct <br /> and/ atnd the Rufas and herein <br /> Regulations of the San f Joaquin <br /> made in compliance � <br /> Local Health District. . �!� <br /> (- Cid — Lot Size PM- <br /> Job Address <br /> (� <br /> s <br /> ddress <br /> Owner's Name Phone <br /> License No <br /> / . S I-2 I Phone �� <br /> . � <br /> Contractor's Name CTION CJ <br /> . <br /> TYPE Of WELL/PUMP: NEW WELL G WELL REPLACEMENT Q DESTRU <br /> OTHER El <br /> SYSTEM REPAIR C <br /> PUMP INSTALLATION ❑ 4 <br /> SEWER LINES:— DISPOSAL FLD. ._ PROP. LINE , <br /> DISTANCE TO NEAREST: SEPTIC TANK: OTHER WELL PITS/SUMPS <br /> FOUNDATION. AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing _ <br /> ❑ Industr'ial C Open Bottom ottott Q Manteca Dia. of Well Excavation_ - -- <br /> Type of Casing Specifications <br /> ❑ Domestic/Private, C Gravel Pack C Tracy ��. Depth of Grout Seal _ Type of Grout <br /> Public # Ll Other O Deka . <br /> Cl Irrigation l{ Approx. Depth C Eastern N P State Work Done <br /> _Surface Seal Installed by — <br /> .,�. _ — <br /> Repair Work Done }i O Type of Pump�— Seating Material{top 50'} _ <br /> Well Destruction 1#0 Well Diameter t — <br /> i Depth l Filler Material (Below 501 <br /> CTION C <br /> TYPE OF SEPT11 I11 C W 11 ORK; NEW INSTAM!5 ON REPAIRlAODITION .:J DESTRU2 ailabie wthiine200 fitted it public sewer is <br /> I Inilstallation wl serve Residence✓ Commercial_— Other_ <br /> r <br /> Number of living units Number of Brooms - <br /> f Water table depth <br /> Character of soil to a depth of 3 feet: �� Capacity r� No, Compartments <br /> SEPTIC TANK # [4- Type/Mfg I— Method of Disposal <br /> _ e 1 <br /> PKG. TREATMENT PLT. O (! Foundation r _ Property Line <br /> ` Y Distance to-nearest: Well - <br /> 1( L p� <br /> ,.;:,,.; -- Q l Total length/size- <br /> r <br /> ength/size = <br /> LEACHING LINE �No. & Length of lines r Property Line-�Q— <br /> Foundation — <br /> FILTER BED 1 Distance to nearest. ",Well _ o <br /> SEEPAGE PETS 7 th -Size~ ..; Number_ <br /> y Line <br /> i SUMPS ❑_ Distance to ne_ar_es!,'- " Well ¢L°undation Property <br /> DISPOSAL PONDS C `' <br /> I hereby certify that 1`l ave prepared this application and'Uiat the woik will be done in accordance with San Joaquin county ordinances,state laws, and <br /> i rules and regulations of the San Joaquin Local Health District:•»«.-- ,w. rmit is the work for <br /> Home owner or licensed agent's signature certifies the following:"I certify that int on iawsoof California."rmance of Contractors hiring or sub-contracting lsignaltuore <br /> employ any person in such manner as to become subject to workman's compensation this <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 /> tlon laws of California. <br /> The app7�­­ <br /> FOR <br /> ll all required inspections: Complete drawing on reverse side. <br /> Date: - <br /> I Signed DEPARTMENT USE ONLY <br /> Date l/-I Z :k 5 Area � --� <br /> Application Accepted by _ r_ _ - <br /> Final In by Date <br /> Pit or Grout Inspection by Data 1 — <br /> Additional Comnronts: <br /> G Stk 466-6781 0 Lodi -369-3621 0 Manteca 823-7104 ❑ Tracy 635 6385 <br /> rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> Applicant- Return all copies to: Environmental Health Pe <br /> T <br /> r _ CK RECEIVED BY DATE PERMIT NO, <br /> 1FEE ED AMOUNT DUE AMOUNT REMITTED CASH - r <br /> i. + EH 1324(REV.101831 4E-U U t <br /> EH 14-26 <br />