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APPLICATION,FOR PERMIT <br /> SAN JOAD.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) or in stall t. ' <br /> he wo <br /> . This application is <br /> Application is hewith a toJoaquinthe San <br /> nCo aqui ordinance lHlth District <br /> for sewage or it t 1 on for we <br /> 111pump and the Rules and Regulationrk herein s of he San Joaquin <br /> made in complianceun <br /> Local Health District.-!" <br /> City t Lot Size <br /> PM <br /> Job Address <br /> Phone J ! <br /> ddress <br /> Owner's Name00 <br /> �--Phone <br /> ddress <br /> License No. <br /> ContractorDESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL d WELL REPLACEMENT ❑ OTHER ❑ [ „t <br /> PUMP INSTALLATION JZFpl,I1CM REPAIR 1:1 �V <br /> SEWER LINES DISPOSAL FLD- PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC.TA_NK: _ _ ,y _ rF(-EI - p1T5/SUMPS V� <br /> - - - ' - FDUNbAT10N' `AGRICULTURE WELL DTHER WELL t }` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> El Industrial Specifications <br /> ❑ Domestic/Private [I Gravel Pack ❑,Tracy Type of Casing <br /> �1 Public E3 Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> L� H P State Work Done J �� <br /> Repair Work Done ❑ Type of Pump + <br /> t Sealing Material (top 50'1 <br /> Well Destruction FJ Well Diameter Filler Material (Below 50'1 <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available wit i 200 feet.) if public sewer is <br /> s <br /> I Installation will serve: Residence— Commercial_ Other ' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: 3 Capacity_ No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Line <br /> Distance to nearest: Well Foundation Property r <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of linest Property Line <br /> ❑ Distance to nearest: : ' Well Foundation <br /> FILTER.BED , <br /> Depth Size Number <br /> ❑ <br /> SEEPAGE PITS - -'^`"°- Pro a Line ' f <br /> ❑ D'+stance to nearest: # _Well ""� ='-FouriHatiori� ; P � . <br /> C. SUMPS' } <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be drtone in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District., <br /> 1 € <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 /> s of <br /> employ anyperson <br /> person in:sulch fy manner <br /> an to become the performancecofthe work for which this perm workmanvis issued,f/shall employ personsisubj subject t ring or b orkman-contract1scompensa- <br /> certifies 9 <br /> tion laws of California." i i <br /> The applicant must call for all required inspections. 'Complete drawing on reverse side`• <br /> ' Title: Date:. _ <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date �J :Area- <br /> Application Accepted by " <br /> _ t <br /> x Date Final Inspection by f `-e Date ° <br /> pitlor.Grout-lnspectbn by <br /> . <br /> Additional Comments: ' x <br /> x <br /> � _ _ ❑Tracy._835-6385---- -•�--.w-�---,.•__, .1�---•.._�.� Ci° <br /> ❑ Stk 466-6781 ❑ Lodi y 369_3¢?1 -C7-hAanteca _823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201' <br /> i r� -�� CK' ' ,, 'RECEIVED BY t?ATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITD� CASH` <br /> INFO . <br /> �-J3s 15 io <br /> .+ EH 13-24(REV.I/A 57 -- <br /> EH 14-26 <br />