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r <br /> a APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' r Telephone (209) 466-6781 <br /> i <br /> + PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) dirk licanon is <br /> install the w <br /> Application is hereby mh SanoJthe oagS n County O dinance No.549 for sewage o INo 1862 forcwellldpump and the Rules and herein <br /> Regulations.of the S, This appn Joaquin <br /> fl <br /> made in compliance wit <br /> `Local Health District. d <br /> ;.� ) r 4?d 1 Lot Size PM <br /> // $ <br /> ,__ "t� U City <br /> Job Address'/ � � i <br /> 0-vp � Phone <br /> [1 •` Address// S1C) <br /> _.Owner's Name l <br /> r� s11111111 ­11I'll <br /> Address <br /> License roo!�2 - Phone_ <br /> Contracta DESTRUCTION O'+ <br /> - NEW WELL WELL REPLACEMENT ❑ <br /> TYPE OF-WELL/PUMP SYSTEM REPAIR ❑ OTHER ❑� <br /> PUMP INSTALLATION �S <br /> DISTANCE TO NEAREST;-.SEPTIC TANK SEWER LINES " DISPOSAL FLD. PR <br /> P. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ( f PITIISUMPS <br /> u(l <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> i <br /> INTENDED USE ---� 7 Dia.pf`Welk Casing <br /> Industrial <br /> ❑ Open Bottom ❑ Manteca Dia of Well Excavatka�� Specifications <br /> k Gravel Pack © Tracy"- , ` Type�of Casing . Y ��; �( ��tiZ <br /> E Domestic/Private .. _ — Y. epth Q rout ea ___ yp of Grout <br /> Cl Others elta _ <br /> l'1,Public Surfpce Seal Installed by <br /> A rox. Dept I 1 Eastern <br /> 1,;1 Irrigation — <br /> Approx. H P / � State Work Done <br /> Type <br /> Repair 1;6k I- Done ❑ T yp of Pump <br /> Sealing Material (top 50'1 <br /> Well Diameter <br /> t Well Destrricton Q --t <br /> Depth Filler Material (Below 50') G- <br /> TYPE OF SEPTIC V115K: NEW INSTALLATION l 1 REPAIRlADDITION I 1 DESTRUCTION I I aNailablerw within am p etrt�ed pi l f sewer is. <br /> � Commercial Other <br /> Installation will serve: Residence <br /> Number of living units: N her,of,bedrooms Water.table de th <br /> �- <br /> 'Character of soil to a depth of 3 feet: _ No. Compart ants <br /> ❑ Type/Mfg t Capacrty��.�- _: ,, <br /> SEPTIC TANK '. Method of Distiosal <br /> PKG. TREATMENT PLT. ❑ I <br /> Distance to nearest: <br /> Well Foundation Property Line <br /> - Total length/size— <br /> LEACHING <br /> ength/size LEACHING LINE �` Cl` No. & Length of lines r—�.r�property tine i <br /> ❑ Distance to nearest: Well Foundation—_ <br /> FILTER BED t <br /> Number, <br /> SEEPAGE PITS I I Depth <br /> Size - t <br /> Foundation y Prope ty Line <br /> SUMPS Ll Distance to nearest: Well - <br /> DISPOSAL PONDS <br /> certify that I have prepared this application and 1hat'the work will be done in accordance with San <br /> I hereby Joaquin sou ty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Districtg <br /> Home owner or licensed agent's signature certifies the followrn l certify that in the performance of the work for which this pe mit is issued, i shall not <br /> l iu,, <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contracto�nhhirin soft io workman's otracrcompensa <br /> certifies the following: "I certify that in the performance of the-work for which this permit-is.issued 6shall employ pe ! I <br /> tion taws of California." <br /> The applicant st call for II re uired inspections. Complete drawing on reverse side. _ <br /> �/T Date: <br /> Signed X_� <br /> FOR DEPARTMENT USE ONLY C� 1 <br /> f Date r L Area r <br /> Application Accepted by ate <br /> / <br /> F * / d Date Final Inspection by <br /> Pito Gro nspection by <br /> l .\ <br /> Additional Comments: <br /> { I-] Stk" 466-6781 ❑.Lodi-_369-3621.�,r ❑ Mantece--�823-7J04= - .-0-Tr Ave., <br /> ox 200 , Stk., A il52 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.P,O. Box 2009, Stk., CA 85201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> l +.EH13-241REV.riµsr 1 OfJ <br /> EH 14-2e <br />