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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STftKTON, CA <br /> Telephone 1209) 466-678) <br /> PERMIT EXPIRES VYEAR FROM DAVE ISSUED <br /> (Complete in Triplicate) <br /> f <br /> r install the <br /> Application plhance wrrth Sano the Joaquin County OrdinaJoaquin lnde Na.549 for sewage or ealth District for a permit <br /> No 1862 forcwcation is <br /> ell/dpuomp and the Rules and rk 'R Regulations of the San n described.This j Joaquin <br /> Local Health District. <br /> City Lot Size PM 1 <br /> Job Address <br /> Owner's Name < <br /> Address Phone <br /> Contractor1n AddressE_,�� �� License No. Phone <br /> TYPE OF WELL/PUMP: /CNEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> El industrial C1 open Bottom (71 Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy yp Type of Grout — <br /> [-1 Public n Other 4 171 Delta Depth of Grout Seal - <br /> I I Irrigation —.-Approx. Depth i I Eastern Surface Seal Installed by <br /> 4 Repair Work Done ❑ Type of Pump H.P. State Work Done , <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth / %� Fillet Material (Below 501 • -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION DESTRUCTION_ [ 1 INo septic 'system permitted if public sewer is <br /> � ' available within 200 feet.) <br /> . <br /> Installation will serve: Residence. Commercial_ Other : <br /> Number of living units: Number of bedrooms yt <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel[ Foundation-----�-'I --- " <br /> Property Line <br /> LEACHING LINE No. & Length of lines ~�o Tota[: `ngthlsi2e 1� <br /> ' 'T�.2 �— <br /> FILTER BED ❑ Distance to nearest: Well Foundation — PropeErty Line <br /> SEEPAGE PITS I I Depth Sizeys . Number <br /> SUMPS Ll Distance to nearest: Well Foundation- — t Property-Line " <br /> DISPOSAL PONDS ❑ -- - -1,_. } <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 OFsCrict�%. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance otthe 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."'Contractors hiring-or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit iisissue8ji_shall employ persons-subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all r aired i pact/ioonns. Complete drawing.on reverse side. f <br /> Signed X /A �/"� Title: Date: ` r <br /> r- <br /> FOEPARTMENT USE ONLY/ <br /> Application Accepted by <br /> r� Date Area / <br /> ( Date <br /> Pit or Grout Inspection by .Date Frrtal Inspection by <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El 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 /> i <br /> FEE --AMOUNT-DUE.,,-.-..�,. AMOUNT REMITTED-.-d 4 CASH_RECEIVED-13Y---�� --DAATE— <br /> INFO" <br /> _. PERMIT'NO " h �— <br /> - <br /> +.EH 13-24 TREY.I/B 5) <br /> EH 14-2e <br />