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- �� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT JUN 2 2 1994 , <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA ENV1ROt4Mg4TAL HEALTr <br /> Telephone 42091 466-67$1 <br /> i PERMIT EXPIRES 1-YEAR FROM DATE ISSUED pERM1T/SERVICES <br /> (Complete in Triplicate) <br /> is <br /> �. . n Local <br /> Applicationlco <br /> mpliance made t the <br /> San <br /> Joaquin Qty Ordinance Nto. 549 for sewage or h District for a permit <br /> 1862 forcwe I arid/or <br /> and the Rules and Regulations of tfhe San'Joaquin <br /> made P � <br /> Local Health District. r 4.1 <br /> ' PM <br /> City Lot Size <br /> Job Address <br /> Address '' Phone <br /> Owner's Name t <br /> < ?- 3—Dense No. 3/ Phone <br /> k Gontractor Address <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTRLLATkON <br /> SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 'Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> I ' Type of Casing Specifications <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> to Public F 1 Other , ❑ Delta _ Depth of Grout Seal <br /> I I i Irrigation _,_Approxi Depth l I Eastern t Surface Seal Installed by <br /> e of Pura H.P. -- State Work Done <br /> Repair Work Done 9 TYp yp• = <br /> Well Destruction ❑ Well Diameter ,„Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AOD1TION I I DESTRUCTION I 1 alvailableo seiw thin 200 feet.)stem 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: No. Compartments <br /> — _Q Type/Mfg . .Capacity - <br /> SEPTI—TANK <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Q <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Number � <br /> j SEEPAGE PITS I I Depth,ISr e'Property Line <br /> SUMPS �❑- Distance to nearest: Well Foundation <br /> a_ <br /> DISPOSAL PONDS '❑ 4 Ill <br /> I 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 /> ,rules and regulations of the San Joaquin Local Health District. <br /> 'I certify that in the performance of the work for which this permit is issued, I shall no <br /> Home owner or licensed agent's signature certifies the following: <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 <br /> certifies the following: "{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 mu all for all fired inspections. Complete drawing on reverse side. ` <br /> Signed Tit ie: <br /> Data: <br /> OWDEPARTMENT USE ONLY �� �/� . <br /> Date Area <br /> f Application Accepted by <br /> � Final Inspection hyr�" - Date <br /> Pit or Grout Inspection by Date Vie• <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE �PtEO- <br /> INFO <br /> 'FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> r .n <br /> -EH 13-24(REv"t/n s i 4 ��� •C <br /> EH 14-28 <br />