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i <br /> # APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> n described. This app <br /> Application is heieby made to the SanCoorcation is <br /> aqui Ofd Hance No.549 for sewage or ocal Health District for a permit <br /> No. 1862 for construct <br /> and/or <br /> elllpump and the Rules and iR Regulations of the San i Joaquin <br /> made in compliance with San Joaquin ty <br /> C.J R <br /> E <br /> Local Health District. ,, � .4�"� /� <br /> PM <br /> City <br /> �i' �' �`�', City Lot Size <br /> Job Address <br /> I Phone <br /> Owner's Name <br /> Address <br /> t ; _ l� License No.+a� hone <br /> Contractor + Address _ <br /> TYPE OF WELL/PUMP:• w NEW WELL ❑ WELL REPLACEMENT L] DESTRUCTIONRC�— <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ 4 s <br /> SEWER LINES, DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK p <br /> t <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 El Manteca Dia. of Well Excavation Specifications { <br /> ElDomestic/Private ❑ Gravel Pack, ..❑ Tracy Type of Casing +, <br /> r [1 Delta' Depth of Grout Seal Type of Grout <br /> h M Public «�. n Other . A <br /> I I Irrigation -.ApProx. Depth L i Eastern Surface Seal In by E <br /> r - State.�Nork Done _ r <br /> Repair Work-Done C7 - Type of Pimp• H•P` - <br /> Well Destruction ❑ Well Diameter Sealing Material )top 50'l <br /> t_ Depth __I Filler-Material (Below 50')- <br /> TYPE OF SEPTIC WORK: °NEW INSTALLATION REPAIR/ADDITION i 1 DESTRUCTIONP,I'�I�JNo septic <br /> syitem permitted <br /> itted if public sewer is <br /> Commercial_ Other = Y <br /> Installation will serve: 'Residence _ __ <br /> Number of living units: � ' Numberof'bedrooms� t <br /> s ' Water.table depth'' <br /> Character of soil to a depth.of 3 feet: <br /> Z, Capacity = * No:'CompartriSents ^" <br /> SEPTIC TANK L1 ;Type/Mfg <br /> Method of-,Disposal <br /> PKG. TREATMENT PLT. Cl <br /> Distance to nearest: Well Foundation _— Propeht .Line�­m7, � <br /> - <br /> No..& Length of lines Total fengthlsize _ <br /> LEACHING LINE <br /> Property Line' <br /> FILTER BED ❑ Distance to nearest: Weli Foundation z <br /> -Depth Size Number <br /> SEEPAGE PITS ...a_.•I I Depth - i <br /> SUMPS ' 0 Distance to nearest: Well Foundation ' Property Line {' <br /> DISPOSAL PONDS ❑ } <br /> I here;y certify that I have prepared this application and that the work will be done in accordance;with'San Joaquin,county ordinances, state laws, acid ` <br /> rules and regulations of the San Joaquin Cocal Health Di§trict. <br /> l+ Homeowner or licensed agent's signature'certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <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 followin 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 /> g- ,. 1 <br /> I <br /> tion laws of California."The applicant must call for al required inspections. Complete drawing on reverse side. <br /> - a ----.••-*--. --�- _.,.....- �^- r} .. /... r F <br /> r f <br /> Title. a�r� Date: <br /> I Signed X { <br /> a _ <br /> FOR EPARTfNENT USE ONLY ,,// I t <br /> f 1 <br /> Date Area <br /> Application Accepted by �/� <br /> Pit or'Grout Inspection by Date Final inspection by <br /> Additional Comments: <br /> EI Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1_1 Tracy 835-6385. f <br /> Appli�a nt- Return all copies to: Environmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 20091 Stk., CA 95201 r <br /> } r _ _ <br /> FEE _..._ _._ CK <br /> AMOUNT DUE AMOUNT REMITTED s CP5H •-j�" ''RECEIVED-BY�. w DATE PERM7IT NQ:^ - <br /> tNF <br /> EH 13-24(REV.i/R 51 <br /> EH 14-28 ��11 - <br />