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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELi ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> aquin the San Jo �j1 - ams""San Joaquin <br /> Application <br /> hereby withade SanoJoaquin County ordinance No.District549 for sewage or INo. 1862 forcverellldpump and the Rules a/or install the w m 1 ul Ib� This apple nes <br /> made in compliance <br /> Local Health District. 6 3F f I 'ENVIROMENTAI_ HEALTH <br /> O City Lot Sid` E§ <br /> Job Address i� I: <br /> I� <br /> 'L L �,ddress ��� u ,y ne # <br /> Owner's Name ✓ <br /> Contractor <br /> Address 2s License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:oSEPTIC <br /> -TANK-.. <br /> SEWER LINES DISPOSAL FLD-�PROP. LINE <br /> ,FOUNDATION <br /> AGRICULTURE WELL OTHER WELL "PITSISUMPS <br /> a ii <br /> INTENDED USE ; TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Wel!Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 'Specifications <br /> rm <br /> Gravel Pack ❑ Tracy Type of Casing <br /> Domesticl Private ' Type of Gr t <br /> } ❑ Public / <br /> ❑ Other Cl Delta Depth of Grout Seal <br /> ❑ Irrigation d �Approx. Depth ❑ Eastern Surface Seal Installed by <br /> — <br /> Ll P State Work Done <br /> Repair Work Dor�;i ❑ Type of Pump Sealing Material (top 50'} <br /> Well Destruction ❑ Well Diameter —�� Filler Material (Below 50'1 <br /> + Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPARVADDITION ❑ DESTRUCTION ❑ aNailablelwit Ine200 permittedtpubric is <br /> t <br /> lnstallFion will serve:. Residence Commercial Other <br /> Nunoer of living units: Number of bedrooms <br /> Water table depth <br /> i Character of so+l to a depth of 3 feet: Capacity No. Compartments <br /> SWT1C TANK ! ❑ Type/Mfg �- <br /> Method of Dispogii <br /> !KG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines PropertyLine <br /> h FILTER BED [I Distance to nearest: Well Foundation <br /> Depth Size Number <br /> SEEPAGE PITS_ 0 :e„ Property Line <br /> SUMPS E3 Distance to nearest: Well Foundation <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 favus, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> such manner as to become subject to workman's compensation laws of California,"Contractors hiring or sub-contracting signature <br /> employ any person in ss the perform <br /> I certify that ance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> certifies the following: <br /> F <br /> tion laws of California." <br /> The appli ant ust call for all requir inspections. Complete drawing.on rev rse side. - <br /> Title: Date: <br /> j Signed - <br /> FOR DEPARTMENT U ONLY <br /> �,y�`I'^'r2. { ► l`^'�"� Date �a" Area b <br /> Application Accepted by N 3(� <br /> Pit or Grout Inspectio <br /> Date Final 1nsppectidn by Date _L 0 ; <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2W9, Stk., CA 95201 <br /> FEE AMOUNT REMITTED RECEIVED BY DATE RMI NO. <br /> l 1NF0 7 0 <br /> AMOUNT DUE CASH <br /> { + EH 13241AEV,t/951 ZJ <br /> t EH 1426 <br />