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-�1 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON / <br /> CA <br /> m + Telephone (209) 466-6781 _ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0" 6 �, e/ <br /> fi. (Complete in Triplicate) <br />} made inion.is hereby compliance with San J alau nade to the nJoaquin Local Health District for a Permit to County Ordinance No.549 for sewage or No. 18construct and/or install the work herein described. This application <br /> Local Health District. for well/pump and the Rules and Regulations of the San Joaquin <br /> Job Address 0 <br /> City Lot Size <br /> Owner's Name a t <br /> PM <br /> Address <br /> Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP:€ nse No. �` U <br /> ]NEW WELL ❑ WELL REP CEMENT ❑ Phone r 1 <br /> PUMP INSTALLATION ❑ DESTRUCTION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> —� SEWER LINES _�_ DISPOSAL FLD. J <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL 0 <br /> PROBLEM AREA <br /> ❑ CONSTRUCTION SPECIFICATIONS Industrial Open Bottom ~~ " <br /> El Domestic/Private Manteca Dia. of Well Excavation 1 <br /> ❑ Gravel Pack ❑ TracyDia. Of Well Casing <br /> C2 <br /> Public ❑ Oiher Type of Casing Specifications <br /> El Irrigation ' i Delta Depth of Grout Seal <br /> —�Approx, Depth ❑ Eastern <br /> Repair Work Done Surface Type of Grout <br /> ❑ <br /> Typetof Pudeal Installed by <br /> Pump H.P. <br /> Well Destruction ❑: Welibiameter State V�/ork Done <br /> Sealing Material (top 50') <br /> Depth Finer Material (Below 50') o <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is 0 l <br /> A <br /> Installation will serve: Residence available within 200 feet.) <br /> once' bedrooms <br /> ial Other�L <br /> Number of living units:�_ Number of bedrooms "� <br /> Character of soil to a depth of 3 feet: op <br /> SEPTIC TANKType/Mfg Water table depth 0 <br /> / PKG. TREATMENT PLT. F1Capacity— Q No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well�� Foundation� <br /> Property Line <br /> LEACHING LINE No, & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size_ <br /> ` Foundation_ property Line <br /> v <br /> SEEPAGE PITS Depth <br /> SUMPS S1Number <br /> ❑ Distance to nearest: Welel l _ z <br /> DISPOSAL PONDS El � Foundation. property Line <br /> I hereby certify that 1 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. 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the per of the work 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 rf California."Contractors 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 C to <br /> tion laws Of California." p y pi►rkns•subject to workman's compensa- <br /> The applicant m c r quired ctions. Complete dra ing on reverse side. <br /> Signed <br /> +tle• , <br /> ' Date; <br /> F R DEPARTMENT USE ONLY f <br /> ;.Application Accepted by p <br /> Date4Q—(! Ar <br /> Pit r Grout Inspection by <br /> Date - Final Inspection by <br /> Additional Comments: ate <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 <br /> 0 Tracy 5- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 EHazelton Ae.6385P.O• Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT"N0. <br /> EH 13-24IREv.10/831 S,- � <br /> EH 1428 <br /> 14—Zi <br />