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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> cation is <br /> madle ntcompl ante with SanoJoaqu nthe San County OrdinaJoaquin nce No.District Health 549 for sewage or'No. 1862 for well/pump and the Rules and R gulations of he Sant to construct and/or install the work herein describ , This t Joaquin <br /> Local Health District. <br /> City �"�'" Lot Size j PM <br /> Job Address / <br /> Phone <br /> Owner's Name � Address <br /> Contractor's Name ( lal)J5 100License No. 1;2/1 <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL--REPLACEMENT"❑ 4 DESTRUCTION-0— <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUGTdON_SP_EGIFICATI0N5.....,, <br /> 1-1 Industrial LI Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic I Private _ 4- ❑_Gravel Pack _ ❑ Tracy,.-.-.--�.. , Type of Casing s Specifications <br /> ❑ <br /> Public Other ❑ Delta .Depth of Grout Seal Type of Grout <br /> i _ ��-._ ' e 3 . <br /> ❑ Irrigation ,� ---Approx. Depth Y3 Eastern Surface Seal Installed by <br /> Repair Work Done Cl Type of Pum1" <br /> p �"N.P " State Work Done <br /> Well Destruction ❑ WeIISDiameter Sealing Material {top 5011 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feat.} . <br /> Installation will serve: Residence X_ Commercial; Other <br /> Number of living units: Number of bedrooms 1 <br /> 1 Water fable depth `} O <br /> Character of soil to a depth of 3 feet: ,,�1_ <br /> e4r ���f fR Capacity No. Compartments <br /> SEPTIC TANK �, Type/Mfg + <br /> PKG. TREATMENT PLT. 11c= Method of Disposal <br /> Distance to nearest: Well /,40 Foundation _— Property Line_CZ! <br /> VT Total length/size1210 <br /> ¢ <br /> LEACHING LINE 6ZL No. & Length of lines <br /> FILTER BED- ❑ Distance to nearest: Well DB �7R Foundation . �U _ Property Line <br /> SEEPAGE PITS DZ Depth Size— 1=3 Number <br /> SUMPS ❑ Distance to nearest: Well /Sd Foundation_Z16 _ Property Line <br /> s <br /> DISPQSAL 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 /> Home 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 subject to workman's compensation laws of 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must ca all requped ins tions. Complete drawing on reverse ida. <br /> 4 Signed Title: ' <br /> Date: ' Z�' <br /> f F �PARTMENT USE ONLY 7 <br /> _ _ r ,/ —E Date �` Area , <br /> Application Accepted by � <br /> Pit or Grout Inspection by �r Dated Final Inspection by �' Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I3 Applicant- Return all copies to: Environmental Health Permit/Servioss 1601 E. Hazelton Ave.. P.O. Box 2009, Stk., CA 95201 <br /> 4 � <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE ' PERMIT`NO. <br /> INFO <br /> + Eli13-24(REV.10!831 1� s � �� <br /> EH 14-28 L 1 - <br />