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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRI N : (` 2.r <br /> 1601 E. HAZE T ON AVE., STOCKTON, C _ <br /> Telephone (209) 466-6781 i w 0 1985 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED" d- FAL-1 <br /> (Complete in Triplicate) PER .Ili App <br /> cation is <br /> madlec inion is compliance wieseby th San Joaquin Cou Qty Ordinance Nade to th e San Joauin Local to. 549 for sewage or h District for a permit <br /> 1862 for wewpump and the Rules and Regulations of the Sant Joaquin <br /> Local Health District. <br /> S <br /> �t/J'CJ City Lot Size PM <br /> Job Address <br /> Owner's Name ��hh}} <br /> /.J (>"h���� Y'_ Address f a '— Phone a a! <br /> � r� <br /> Address re �( License NoL, 7�Phone <br /> Contractor '^�-�" <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT C) DESTRUCTION LJ <br /> PUMP INSTALLATION El <br /> REPAIR ❑ OTHER L3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - AGRICULTURE WELL _OTHER WELL. PITSISUM.PS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca Dial of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> R f"1 Public n Other Cl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> ,Gtiffl _ <br /> Repair Wok Done C7� Type of Pump H,P. State Work Done 6 <br /> Well Destruction ❑ Well Diameter Sealing Matefial (top 50'1 <br /> Depth Filler Materiali18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 Rt i:`AIRlADDITION l i DESTRUCTION l I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> t g y <br /> Character of soil to a deptWof 3 feet: Water table depth <br /> SEPTIC TANK ❑ „Type/Mfg Capacity No. Compartments +�f <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well_ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines. d Total length/size <br /> FILTER BED ——R-^"Distance-to-nearest- -WeR-- foundation-- Property-L•ine - --- <br /> SEEPAGE PITS l I Depth Size k Number <br /> Fo <br /> SUMPS L1 "Distance to nearest: Well ' ; undation Property Line <br /> DISPOSAL PdNDS ❑`" '- _. - _ .. . <br /> y I hereby certify that I have prepared this application and that the wok will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> Home owner 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 /> i'. 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 /> tion laws of California." <br /> The applicant t call for ail ed inspectio s. Complete drawing on reverse side. `t} <br /> i <br /> Signed L� le: Date: <br /> t <br /> I FOR bEPART �ENT USE ONLY <br /> Date ✓ <br /> Application Accepted by Area <br /> Pit or Grout Inspection by Dizte Final lnspectian by Date <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca X823-7104 '; ❑ 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 /> FEEAMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 1924(REV.t/H 5) <br /> EH 14-2e +�—� <br />