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Y E S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA No <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> r install the work <br /> . This <br /> madeinApplicationfiance with Sano the Joaquin County ordinalHealth District for a nce No.549 for sewage or It to No. 1862 forcwellldpuomp and the Rules and herein <br /> Regulations of the Sancation is <br /> Joaquin <br /> made in compliance <br /> Local Health District. / 100 <br /> ts/ r . 0 ,l� /V11�t of Size <br /> I City <br /> Job Address Phone <br /> �j J7 r� <br /> ✓ Q� / �d C <br /> Owner's Name Address <br /> Contractor Address <br /> License No. Phone_ <br /> WELL REPLACEMENT ❑ DESTRUCTION D I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION d <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Specifications <br /> Type of Casing _ _ <br /> D Domestic IPrivate D Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout — <br /> 1.1 Public [7 Other i 1 Delta <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal installed by <br /> H <br /> Repair Work Done fa Type of Pump <br /> P State Work Done <br /> Well Destruction- ❑ Well-Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50'] <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l 1 DESTRUCTION .allo sep7v,j2 system <br /> Permitted if pPC ublic sewer is <br /> Installation will serve: Residence, Commercial Other <br />` Number of living units: Number of bedrooms Wepth <br /> Character of soil to a depth of 3 feet. NmentsSEPTIC TANK D Type/Mfg CapacityMsposal <br /> PKG. TREATMENT PLT. ❑ r' <br /> Distance to nearest: Well <br /> Foundation Property Line r+ <br /> Total length/size <br /> LEACHING LINE D No. a Length of lines <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGE PITS 4 I Depth Size Property Line <br /> SUMPS D Distance to nearest: Well Foundation P y <br /> DISPOSAL PONDS ❑ <br /> I 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 /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subjecsignature <br /> t to workman's compensation laws issueof-Cald, <br /> I shall <br /> ploy Contractor'shiring <br /> to workmantlscompensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p f <br /> tion laws of California." �y <br /> The applicant,rl}tist cal fo I squired i spections. Complete drawing on reverse si(/j�yJt L Title: Date: <br /> Signed X_ /' OR DEPAR ENT SE ON��Y <br /> •--" - l� Are <br /> Datea <br /> n s <br /> Application Accepted by z5fk <br /> c.._l f Q <br /> Data v Final inspection by �' l Date <br /> Pit or Grout Inspection by . . . <br /> Additional Comments: v/ <br /> D 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 CK RECEIVED BY DATE PERMIT NO. <br /> r INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> r.EH 13-24(REV.1/"51 3r <br /> EH 14-26 <br />