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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 f. :. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .,, <br /> ,;. (Complete in Triplicate) <br /> all the work <br /> ed.This <br /> n is <br /> Application is hereby rth Sanothe San Joaquin Joa u'n County Ordinance No.al Health 549 for sewage orpermit <br /> No.-1862 forcwellldpump and the'Rules and 1Regu�latio of the Sa Joago u n <br /> made in compliance wi q <br /> Local Health District. <br /> 0 1O <br /> ' It-fJ�Kd PM <br /> "7 ]� 0 N, City Lot Size_ <br /> Job Address _ 6 <br /> � - <br /> Owner's Nam -t A/7J � ekAddress <br /> Contractor C[ Address .6 <br /> C �� License No63�_ Phone��� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ V <br /> PUMP INSTALLATIO SYSTEM WEPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD ' PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK - _.,. � Ea�b.; , <br /> FOUNDATION AGRICULTURE WELL_ .OTHER WELL _ PITS/SUMPS <br /> INTENDED`USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> pomestic/Private ❑ Gravel Pack L3Ca <br /> Tracy Type tf�sing� —� � Specifications <br /> ❑ Other ❑ Delta Depth otGrout SeaI Tyle of Grout <br /> ❑ Public .� <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 4 <br /> H p State Work Done 44 Ml <br /> Repair Work Done )( Type of Pump -, <br /> Sealing Materialt(fop-50') <br /> Well Destruction El Well Diameter .— 9 <br /> Depth Filter Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑,SPD�TRUCTION ❑ aNailabPeiwithm 20D permitted if public sewer is <br /> nstallation will serve: Residence's Commercial��r therk <br /> I <br /> N,Larmw,of living units: Numberlof bedrooms A4w,a... ... <br /> Character o o a,depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK a/Mfg alb CapacityNo. Compartments y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t Distance to nearest:, Foundation Property Line <br /> l <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines) <br /> FILTER BED Ll Distance to nearest: Well Foundation erty Line <br /> SEEPAGE PITS ❑ DepthSize ik Y Number <br /> ❑ Distance to nearest: Well "/ ~Foundation- � � Property Line <br /> SUMPS - <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application 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."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appiicant st a I fo I required inspection�late drawing on reverse side: Z .� L <br /> �f(�(/Lf/t if Cllr . Title. 7t Date: r — <br /> Signed ' <br /> 0 FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by V-247 <br /> Date Final Inspection by Date <br /> Ph or Grout Inspection <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Monte 823-7104 ❑ Tracy 835,63✓35 <br /> A 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C <br /> I , <br /> l <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY :DATE PERMIT'NO. <br /> INFO �^ <br /> +EH 13-24(REV. 7 <br /> EH 14-28 <br />