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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin lHealth <br /> District for a permit to construct and/or install the work herein described.TMs application is <br /> made in compliance with San Joaquin County ordinance <br /> Local Health District. <br /> City PM Size ` - PM <br /> Job Address <br /> 4 -Address'- <br /> 'a, <br /> Address_ 1 <br /> Owner's Name} <br /> r 3 Phone ^p�` l" <br /> �sel� S f1"&S License No. <br /> Contractor's Name WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ' '� - �OTHER ❑ <br /> k, PUMP i�INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES � DISPOSAL FLD. "PROP- LINE, Ul <br /> DISTANCE TO NEAREST: SEPTIC TANK —�- OTHER WELL PiTSISUMPS <br /> FOUTV�ATION_ - —AGRICULTWURE- ELL P <br /> s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Dia. of Well Excavation 0 <br /> ❑ lndus�rial ❑ Open Bottom `❑-Manteca Specifications � <br /> ❑ Tracy Type of Casing <br /> 1 ❑ Domestic/Private ❑ Gravel Pack I - Type of Grout t <br /> iDepth of Grout Seal <br /> [-3Public ❑ Otf��er ❑ Deka wx. <br /> __L-Approx. Depth ❑ Eastern ! -Surface Seal Installed by <br /> ❑ Irrigation - i ° �-= St=_WoTk_DoM W _ <br /> I f H.P. <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50') <br /> E Well Destruction ❑ Well-D;ameter _ �. <br /> Dept!F ' " Filler,Material (Below 50'1 <br /> f <br /> TYPE OF SEPTIC WORK: NEN1'fNS��AL-L��1Ofd`L'�REPAIR•/ADDITION. DESTRUCTION available within 200 feet.)C7 (No septic system permitted if public sewer is <br /> Installation will serve: ResidenceCommercial— Other <br /> Number of living units:_0 Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: € Capacity No. Compartments ' <br /> ❑ ,Type/Mfg <br /> SEPTIC TANK a _ ,. Method of Disposal { <br /> PKG. TREATMENT-PLT. ❑ ;`I! f A Foundation Property Line # " <br /> Distance to nearest:,„;- Well <br /> � Total length/siz <br /> / e <br /> LEACHING LINE !vr No• & Length of lines / Foundation _/x - Property Line <br /> FILTER BED [D Distance to nearest:` Well <br /> e/ / <br /> ` t r .b Size { Number S'j <br /> SEEPAGE PITS ❑ De6t Property Line — <br /> ❑ Distance to nearest: Well Ark Foundation ; <br /> SUMPS 11 II E ` <br /> 4 DISPOSAL PONDS'❑'''�H _ r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance"with San Joaquin cou my ordinances, state laws, and <br /> I rules and regulations of the San Joaquin Local Health District. ; for <br /> Home owner or lone in a mannergas torbecome sub ectot w'orgkman'srcompensation laws fy that in the oof Califorrnithe <br /> 8 Conitractors�huirig!or sub subrmit is-contracting signassued I ture <br /> Home <br /> I employ any pe p arsons subject to workman's compensa <br /> certifies the following: "I cern that in the performance of the ward for which the permit is issued,i shall employ p 11 <br /> tion laws of California." <br /> The applicant call for alillrequired inspectComplete drawing on reverse side. <br /> Title:— Dafe: <br /> j Signed _ -: L '. <br /> FOR DEPARTMENT USE ONLY r <br /> z I p — <br /> S Date r Area Q <br /> .Application Accepted by v r 5y f I�'� "d /1�e �n� 4t <br /> Date�— Fin I Inspection b Date e <br /> Pit or Grout Inspection byD nor v� 2- Z,9, �3o - Prnp�r�ios �.r <br /> ikWzs ln� ��I>! rrrj <br /> Additional Comments: ❑ Manteca 7104 ❑ Tr y 835 6385 <br /> ❑ Stk 466 6761 ❑ Lodi 369 1 Stk., CA 95201 <br /> Applicant- Return all copiesito-. Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED CASH _ RECEIVED BY [DATE HPE711MIT1'NU4] <br /> f 4 EH 1&24(REV.10/eX <br />