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. i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> permitIth District for a construct and/or <br /> Applicati wrlttth Sanade o the S nnCo aquin Local Hea unty O d cants No. 549 for sewage or No. 1862 forwell/pump and the Rules and'Regulations application of the SanJoaquin <br /> compliance <br /> made In <br /> Local Health District. <br /> r r <br /> t l City xe of Size PM <br /> Job Address <br /> d res, <br /> - Phone <br /> 93/ <br /> Owner's Name <br /> f �G JL.icense'iVo o4 Phone <br /> Contractor' y M Address G <br /> TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION b SYSTEM REPAIR ❑ OTHER ❑ <br /> +y _ - -—IN <br /> _._. ._ <br /> DISTANCE TO NEAREST:-SEPTIC'TANK- ! SEWER LINES DISPOSAL FLD. PROP. LINE 49:' " <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT515UMPS T��� <br /> w <br /> ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I�L <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy, Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Sea Type of Grog; <br /> F1 Publicr <br /> I I Irrigation --Approx. Depth I Eastern Surface Seal Installed by , F1 - <br /> Repair Work Dane ❑ Type of Pum__p - H•P• state Work Done <br /> Sealing Material (top 50`1 r <br /> Well Destruction ❑ Well Diameter 9 p <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1"I REPAIR/ADDITION ! I DESTRUCTION I i septic system <br /> 20D permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other v <br /> Number of living units: s. Nurri&3r of bedrooms <br /> Water table depth <br /> j'Character of soil to a depth of 3 feet:. <br /> `" <br /> SEPTIC TANK ❑ Type/Mfg'" R`. Capacity No. Compartments 4 <br /> PKG. TREATMENT PLT. ❑ ,. T Method of Disposal <br /> Distarice to nearest: Well' 'Fdundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Y Notal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I F Depth '•Size Number <br /> SUMPS 'Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared thisfapplicatir hand 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 performance of the wank 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 performance of the work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The app7Accepted <br /> ll luifed inspections. Complete drawing on ;averse ide. <br /> A91 - f <br /> /' Title: Date: Q u <br /> Signed . <br /> R DEPART ENT USE ONLY <br /> ApplicaV � DateArea <br /> Pit orGDatnal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO _1�a; yln <br /> 2�26 OL <br /> ✓UJi 1UC of}U( <br /> +.EH 13-24(REV.i/n 51 r--,�,dam <br /> EH 14-26 <br />