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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> i 1601 E..-HAZEL TON AVE ., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. y r <br /> , ,. <br /> Job Address City Lot Size PM <br /> Ad ss Phone <br /> Owner's Name <br /> Contractor /�� Address!9 v icense No._A Phone <br /> t <br /> TYPE OF WELL/PUMP: NEW WELL,07 WELL REPLACEMENT ❑ DESTRUCTION ❑ a <br /> PUMP INSTALLATION , SYSTEM REPAIR ❑ OTHW❑ <br /> - <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS 't_;AGRICULT.URE WELL OTHER WELL PITS/SUMPS �1 <br /> INTENDED USE TYPE'OF'WELL "�PROBLENI AREA--CONSTRUCTION-SPECIFICATIONS x <br /> Mndustrial F-1OpenBottom L1 Manteca Dia. of Well Excavation _ Dia. of Well Casing $ <br /> omestic/Private ,�GraJel_Pack• "" 'C Trak cy� N Type of`Ca g �— Specifications <br /> ❑ Public ❑ Other. ---"----0`Delta��-----""Depth of-Grout.Seal �� � Type of Grout � <br /> ❑ Irrigaponj Approx.-Depth <br /> ----E] Eastern -Surface Seal Installed by <br /> Repair ILVofk Done ❑ Type of Pump _ _ H•P• 1 State Work Dane ! <br /> Well Destruction ❑ Well Diameter _ f-"t. Sealing�4llaterial (top 50')� <br /> Depth `► 743 f�. Filler Material'{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C] DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence Commercial JZ-Other <br /> Number of living units: 1 Number of bedrooms_s <br /> Character of soil to a depth'of 3 feet: „ "�� �`�, i Water table depth �. <br /> SEPTIC TANK ❑ Type/Mfg t"� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } F .>.�--�-�-# Method of Disposal <br /> D Distance to nearest: f. <br /> , Well IPI Foundation "Property Line V <br /> LEACHING LINE ❑ No. &,Length oft lines J Total length/size <br /> FILTER BED Q Dista e�fo nearest: Well '� � Foundation` { Property Line <br /> CJ <br /> SEEPAGE PITS ❑V Depth _ - --—Size t Number i <br /> SUMPS Elc Distance to nearest: Well Foundation °•- Property Line <br /> DISPOSAL PONDS ❑ l lE " tom y` r <br /> I hereby certify that I have prepared this application and that the work will be done in accordande with San Joaquin county ordinances, state laws, and <br /> ' rules and regulations of the San Joaquin Local Health District. <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 /> certifies the following: "I certify that in the performance of the work for which this permit is issued,;(shall employipersons subject to workman's compensa- <br /> tion laws of California." f l <br /> The applicant r II requir2d inspections. Complete drawing on reArse e. <br /> Signed Title: ' 4 Date: <br /> I FDEPARTMENT USE ONLY � kl <br /> Application Accepted by Date Area <br /> Date Final Inspection by Date / <br /> Pit or Grout Inspection by <br /> F:l f <br /> Additional Comments: ' <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 135-6385 - k . <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.�CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE[ PERMIT''NO. <br /> + EH 13-24{REV.1/B 51 4 <br /> EH 14-28 l <br />