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APPLICATION FOR PERMIT <br /> SAN J• <br /> AQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,-TON AVE., STOCKTON, CA Out 1 <br /> -41 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> �'Ef21t�111' r`"i,.f?ViC..ES e <br /> Ith District for a <br /> r< ceJD�t/ _ application is <br /> f( Application `hence wmFi Sano JoaquinCountyOrdinanjoaquin Local cle No.549 for sewage or INo�1862 forconstrucwell/dpump atnd the Ruoles an d'Regulations of Ithe San Joaquin <br /> made in compliance <br /> Local Health District. e <br /> tv <br /> of Size PM <br /> Job Address <br /> Phone. <br /> Owner's Name <br /> -Address ""`� <br /> 1 Phone <br /> Address License No <br /> Contractor ! <br /> TYPE OF WELL/PUMP: NEW WELL _ WELL REPLACE NT,. DESTRUCTION ❑ <br /> �`� SYSTEjV1"REPAIR- - GTI <br /> . .rA.. ,.. - 'PUMP'INS`-ALtnATI� ,rU--m -'' <br /> EWER LINES , DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL / <br /> / ti l <br /> INTENDED USE TYP F WELL € PROBLEM AREA CONSTRUCTION Stion CATI NS Dia. of Well Casing ` <br /> ❑ Industrial pen Bottom LJ Manteca Dia. of Well Excavatio.,n�— _ specifications <br /> I� <br /> Type of Casing �rr®� Sp <br /> ❑ Domestic I Private ❑ Gravel Pack © Tracy yp / Type f Grout <br /> l O�frer p f I Delta Depth of Grout Seal <br /> 4a. rox. De th L I�Eastern Surface Seal Installed by._^ _ <br /> I I Irrigation AP <br /> H.P, State Work Done — <br /> Repair Work'Done ❑ Type of Pump <br /> e <br /> Well Destruction ❑ Well Diameter — <br /> Sealing-Material (top 50'1 <br /> ��/ Filler Material (Below 50'1 <br /> Depthstemperm - . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i:I REPAIRIADDITION t I DESTRUCTION I I aNailablelwithin 200 feet.) <br /> rned if public sewer is { 1 <br /> \Installation will serve: Residence--L­ Commercial —Other <br /> Number of living units: Number of bedrooms Water table depth i <br /> s ; <br /> f Character of soil to a depth of 3 feet:"- Capacity No. Compartments <br /> SEPTIC TANK\ ElType/Mfg <br /> Method ofDisposalI�� <br /> PKG. TREATMENT PLT. ❑ t <br /> Distance to nearest: Well Foundation <br /> Property Line..- I <br /> .5 4 <br /> Total length/size <br /> LEACHING LINE ' ❑ No. & Length of lines Property Line <br /> 1 FILTER BED k ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS` l'1 Depth' �jtlrSize <br /> r -� Foundation Property Line <br /> SUMPS r kx [ ! Distance to nearest: Welf ! <br /> DISPOSAL PONDS" ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, 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,perfomance of the work for which this permit is issued, I shall not <br /> employ any person in such manner asxo 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 performance of the work for which this pe mit ks,issued, I shall employ persons subject to workman's compensa <br /> �. <br /> tion laws of California.'; <br /> The applicant m call for a req ins tions*Complete drawing on rev a side- <br /> -in$ <br /> (y9 Date: - <br /> Signed X. Title: <br /> FOR DEPARTMENT USEi ONLY ' <br /> na <br /> _ . .*. _N Date . <br /> 1 Area <br /> Application Accepted by t <br /> ` <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by .— <br /> Additional Comments: <br /> 'antece x`823-7104; ❑ Tracy 835-6385 <br /> 0 Stk 466-6781 El LO; 369-3621 El M. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2803, Stk., CA 95201 <br /> FEE AMOUNT DUE`. AMOUNT REMITTED')f s, Cf{ RECEIVED BY DATE PERMIT NO. <br /> CASH <br /> INFO —��� e <br /> + EH 13-24 IREV. <br /> 1��� <br /> EH 14-28 <br />