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APPLICATION FOR.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTr <br /> C 1601 E. HAZEL-16N AVE., STOCKTON, CA <br /> 4 Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> "�_ •" . m. :.� (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora <br /> made-in compliance with San'Joaquin_County.Ordinance-No:549 for sewageeor No. 1862 for plump or and)the Rules and Regulations of the San J <br /> ' application is <br /> Local Health District. <br /> ''rt�o �.2,�j ,. ; y oaquin <br /> U <br /> Job Address p P -r � <br /> City ifn Lot Size. PM <br /> Owner's NameJ G A <br /> — "P _ O 1 I^_ AddressiJC <br /> X-- Z- <br /> Phone 6 fJ .� <br /> .7 Contractor ( A!'P Address i 4 l �� LTYPE <br /> OF WELL/PUMP: NEW WELL License No. hone <br /> I� WELL REPLACEMENT ❑ <br /> DESTRUCTION d <br /> I' PUMP INSTALLAT ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ N "1 TSEWER LINESW <br /> DISPOSAL FLDFOUNDATION PROP. LINE <br /> CULTURE_WELL OTHER WELL �PITS/SUMP <br /> S_ � <br /> -¢ <br />( - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ll <br /> I Q Industrial ❑ <br /> pen Bottom ❑ Manteca Dia. of Well Excavat' Dia, of Well Casin <br /> E ❑ Domestic/Private Gravel Pack �eracY T ype of Casing Specifications❑ Public ❑ ter elta Depth of Grout Seal❑ Irrigation Type of Grout <br /> + I'� Approx. Depth q fastern Surface Seal Installed by <br /> Repair Work Done Q Type of Pump H.P. <br /> Well Destruction ❑ Wei 1 Diameter State Work Done <br /> ,i Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (Nn septic system <br /> I 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 Character of soil to a depth of 3 feet: i <br /> SEPTIC TANK Water table depth <br /> ,i Q Type/Mfg Capacity <br /> PKG. TREATMENT PLT. ❑ No. Compartments <br /> Method of Disposal <br /> } Distance to nearest: Well Foundation <br /> �! Property Line <br /> LEACHING LINE ❑ No. & Length of lines ------ <br /> i Total length/size <br /> FILTER BED <br /> ❑ stance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITSai. <br /> ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Wellt <br /> DISPOSAL PONDS q Foundation Property Line <br /> ? I hereby certify that I have prepared this application and that the work will bedonein accordance with San Joaquin county ordinances, state laws, and 4. <br /> .1 rules and regulations of the San. aquin 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 ormance of the work for which this <br /> tion laws of California." 4 ,w r^r permit is issued, I shall employ persons subject to workman's compensa <br /> The applica m_u II for ec$uire ctions`Complete drawing on rev side, <br /> Signed .. <br /> l �. � itle: � ,.•�. <br /> ^ A Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by � -•.� Date—y <br /> { Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> 9 <br /> Date <br /> Additional Comments; �a � Y �� <br /> ❑ Stk 4666781 ❑ Lodi 369-3621 0-M teca 823-7104 ElTracy 835-6385;Applicant- Return all copies to:�Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT,I�DUE AMOUNT RE ITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> +EH 13-24(REV,t 65) <br /> EH 14-28 <br />