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APPLICATION FOR PERMIT <br /> .. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �� k.s� 1601 E. HAZEL T ON AVE., S.TOCKTON, CA <br /> i Ix Telephone (209} 466-6781 �. I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED- :ter <br /> q (Complete in Triplicate) _application <br /> ll the work <br /> Application is hereby made to the San Coun ui Ordi alncealth D5 strict for sewage or No. 1862 fordesc <br /> rmit to or a POcweli/pump and he Rules and rRegulations of the SaJoaquin <br /> made m compliance with San Joaqui County _ <br /> E Local Health District. ? , <br /> 1 U t� J�+ C t�Lot Size PM <br /> Job Address <br /> n ` til �] (,�Jyt��P V �- Phone `�3-Cx�3. <br /> Owner's Name <br /> ���i 1 �J �1 1)L-Lb A- Address ga—� v , <br /> l <br /> ' S�L �"" Address License No.�--�Phone <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER C3} PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL. PITS/SUMPS <br /> FOUNAGRICULTURE WELL <br /> DATION -- h <br /> TYPE OF WELL PROBLEM AREA -CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Casing <br /> -0 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> i ❑ Industrial .-t Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _r Type of Grout <br /> ❑"Other d Delta Depth of Grout Seal <br /> Public Surface Seal Installed by <br /> ( ❑ Irrigation --Approx. Depth El Eastern H.P. State Work Done <br /> q <br /> Repair Work Done ❑ Type of Pump zSealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'i <br /> > Depth <br /> available within 200 feet.) 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-❑ REPAIRI'ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial Other�— 4 <br /> I Number of bedrooms <br /> Number of living nits; Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg ; Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 'pLine <br /> Distance to roperty nearest: Well Foundation � <br /> S � <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length a linesrest: Well Foundation- prope-ty Line <br /> FILTER BED ❑ Distance to nea <br /> Size Number r <br /> SEEPAGE PITS ❑ Depth Property Line <br /> .SUMPS <br /> ElDistance to nearest: Well- Foundation <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. work for this perrnit is is-�ued, <br /> rtify that in the Home owner or licensedsuch manner torbecome subject Ilowing: "I ceto workman's kman's compensation laewsoof California."hContractor's 1hir ng orr sub-cont act ngls gnlature <br /> employ any person rains subject to workman's compensa <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,i.shaH employ Pe <br /> 4 tion laws of California." <br /> The applicant must call-for,all-req ited"inspections:-Complete drawing o reverse side. <br /> ©��Title: ow\ Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> ! Date �^ Area <br /> Application Accepted by �2 <br /> Dat <br /> Date Final Inspe on by <br /> Pit or Grout Inspection byl <br /> Additional Comments: ` <br /> ❑ Stk 466-6781, ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY <br /> CK DATE PERMIT"NO. <br /> INFO <br /> + EH 13-24IREV-1 85) <br /> EH 14-26 <br />