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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209] 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> cation is <br /> Application is hereby made to the County Local <br /> nce Nto. 549 for sewage or h District for a permit <br /> 1862 forcweR/dpump and the Rules and hereindescribed. <br /> of tthe Sais n Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District, <br /> City Lot Size PM <br /> Job Address <br />+• Phone <br /> Address <br /> Owner's Name <br /> Contractor Address <br /> License No,12-SPhone <br /> TYPE OF WELL/PUMP: NEW WELL❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION L3SYSTEM - <br /> SEWER LINES DISPOSAL FLD. PROP. LINE ,. <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing - <br /> ❑ Industrial El Open Bottom- ❑ Manteca Ria. of Well Excavation <br /> Tracy Type of Casing Specifications <br /> Domestic/Private r" ❑ Gravel Pack/1 !" Tl e of Grout <br /> } Depth of Grout Seal IT YP <br /> f`1 Public ❑ Other q�(3 Delta ; <br /> Approx. Depth�li�l Eastern rface Seal Installed by <br /> 1 1 Irrigation — State Work Done — <br /> Repair Work Done ❑ Type of Pump [ H.P, <br /> 21— <br /> Well Destruction ❑ Well Diameterif4A til Sealing Material Itop 50'1 <br /> Depth A •'f 1 Filler Material (Below 50'1 _- <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION ["I RE t I DESTRUCTION I+1-availableseptic <br /> wthin 00 feet.) if public sewer is, <br /> Installation will serve: Residence Commercial {. Other <br /> Number of living units: Number ofjbedrooms <br /> '_ <br /> Water table depth <br /> Character of soil to a depth of 3 feet:_ I iNo. Compartments <br /> I SEPTIC TANK C3Type/Mfg Capacity / <br /> Method of Disposal <br /> PKG. TREATMENT PLT:❑ c <br /> Distance to nearest: Well Foundation Property Line <br /> r LEACHING LINE Cl No. & Length of lines Total length/size V <br /> FILTER BED ❑ Property Distance to nearest: Well Foundation p y Line <br /> t <br /> SEEPAGE PITS f Size Number 1 Depth , <br /> Cl Distance to nearest: Well Foundation Property Line <br /> SUMPS i; - <br /> DISPOSAL PONDS ❑ <br /> I hereby certify-that.L-have-prepared-this application.and,.that_the_work,will_be-done_in_accordance.with_San.Joaquin-county-ordinances, state laws;-and <br /> I rules and regulations of the San Joaquin Local Health District. <br /> t 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, 1 shall not <br /> employ any person in such mariner as to become subject torworkman's compensation laws of Califor``nia,"..Contraceosonsiring r sub-contracting <br /> signature <br /> ig iatur- <br /> «--•�-•certifies•the-foll Ing:`I-certify-that in them performance of•the work for-which this permit-is•issued,i•shalhemploy'p 1 <br /> tion laws o if rnia." <br /> The appli nt st call for al eq r d inspecti . Co late drawing on ev side. <br /> r Title: Date: <br /> Signed X <br /> F R DEPARTMENT USE ONLY C <br /> Data����1 1 3 Area 0 <br /> Application Accepted by t It <br /> Date Final Inspection by Date 6 1 <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385m <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> t EEE CK RECEIVED BY DATE PERMIT'NO. <br /> IEEE AMOUNT DUE AMOUNT REMITTED �+CAS((H/ ff ^'''-t;'('7' 9 <br /> ..tH13-241pEV.r/n5) Sb`^;6 1'� 1 Yip `3�^0D � <br /> �tiQO <br /> EH 11-29 <br />