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APPLI <br /> CAT.ION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,:2.STOCKTON, CA NDltl <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate? <br /> t and/or inall the work herein described. Thiii <br /> Application is hereby with <br /> San Joaquin nCounty OrdinaJoaquin Localnce Nto.DistrictHealh 549 for sewage or per-it <br /> No 1862 forcwell//pump end the Rul s and Regulations of he Sancation is <br /> Joaquin <br /> made in ompllaiance ce <br /> Local Health District. "1 <br /> /. .. . �, <br /> Cityx �.. ; Lot Size �/� UPM <br /> Job Address 1 LL <br /> Phone <br /> XOwner's Name -11/ = Address <br /> Address License No. Phone <br /> Contractor <br /> � NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF ELL/PUMP OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> MSEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Specifications y <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing v <br /> ❑ Public <br /> El Other ❑ Delta Depth of Grout Seal Type of Grout Q <br /> ❑ Irrigation ---Approx. Depth L1 Eastern t Surface Seal Installed by <br /> l H p <br /> Repair Work bone ❑ Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No septic <br /> tiwhtem permitted if public sewer is <br /> r <br /> Installation will serve: Residence Commercial, Other .. <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> j Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation --Property tine <br /> 1 <br /> DISPOSAL PONDS Els ` n accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in a <br /> rules and regulations of the San Joaquin Local Health District. ;- ...,-— i <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performarice 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." Contractor's 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 call for all <br /> Jrequired <br /> diinspections. Complete drawing on reverse side. -� <br /> Title: Date: <br /> Signed X - , <br /> ARTMENT USE ONLY <br /> ! � _ � Area . <br /> _6Dr <br /> r Date <br /> Application Accepted by <br /> lFinal Inspection by �C Date <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369_Wfi l i] 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 /> } <br /> FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24{REV.I/m!5) <br /> EH 1428V <br />