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F` APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL'T ON AVE., STOCKTON, CA <br /> I; Telephone 12091 466- 6781 - <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. r <br /> (Complete in Triplicate) licat' <br /> Application is hereby made to the San Joaquin Local Health On is <br /> D <br /> No. is ell/pump and the Rules and Regulations of the San Joaquin <br /> for sewage or Na- 1862 for wDistrict for a permit to construct and/or install the work herein described.Thisapp <br /> made in compliance with San Joaquin County Ordinance N , <br /> Local Health District. ti <br /> --City Lot Size. PM <br /> Job Address <br /> �- Phone <br /> Address <br /> Owner's Name <br /> License No. phone <br /> Contractor Address WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> l TYPE OF WELL/PUM NEW WELL ❑ OTHER ❑ <br /> INSTALLATION ❑ SYSTEM REPAIR 13LINE <br /> SEWER LINES DISPOSAL FLD. - <br /> DISTANCE TO NEAREST: SEPTIC TA PITS SUMPS <br /> FOUNDATION GRICULTUR_E WELL t� ` �, 0 F - <br /> TION SPECIFICATIONS <br /> —.--INTENDED USE ""y TYPE OF WELL" ""PROBLEM AR Dia. of Well Casing <br /> ❑ Mante Dia. of avation <br /> 11 Industrial El Open Bottom Specifications <br /> V acy Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Grout <br /> clq <br /> ❑`Other ' Delta Depth of Grout Seal <br /> ❑ Public Surface Seal Installed by <br /> ❑ Irrigation pprox. Depth C1 Eastern H.P. State Work Done <br /> Type Repair Work Done LDyp of Pump Sealing Material )top 50') <br /> I Well Destruction ❑ Well Diameter �— - <br /> ! Depth --.Filler-Material-(Below-50') <br /> f available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION rava septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial <br /> Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: p Capacity No. Compartments <br /> ""_SEPTIC TANK ❑ Type/Mfg -7 Method of Disposal <br /> �PKG. TREATMENT PLT.❑ Foundation Property Line <br /> . Distance to nearest: <br /> '_ T Total lengthlsizs <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance earest: WellFoundation <br /> e to n , <br /> Se-e Number <br /> SEEPAGE PITS ❑ Depth i 'Property Line <br /> SUMPS ❑ Distahce to nearest: Well—� <br /> Foundation <br /> I DISPOSAL PONDS ❑ <br /> tI sf4, 1.1 <br /> Thereby certify that V have prepareri'this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 6 rules and regulations of the San Joaquin Local Health District. rk for g <br /> Home owner r licensed such manner tobecome subject Ito workman'srtify that in compensation lawsoof California."Contractor'swhich <br /> hiring r orr sub contract ng signssued, I ature <br /> employ any person m rsons subject to workman's compensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, l shall employ pe <br /> tion laws of California." ; t <br /> The applicant must call or all required-Yl inspections. Complete drawing on reverse side. <br /> ' gam Title:, Date: <br /> Signe <br /> i FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by Date /� r <br /> Pit or Grout inspection by <br /> Date_ Final Inspection by <br /> k Additional Comments: <br /> ❑ Stk 466-6781 LJ L i 369-3621 p Manteca 823-7104 ❑•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 /> F, <br /> p CK RECEIVED By DATE PERMIT'NO. <br /> FEE - gMOUNT DUE AMOUNT REMITTED CASK <br /> INFO <br /> i+ EH 13-24IpEV.��AS� - <br /> EH 14-26 <br />