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ii <br /> APPLICATION FOR PERMIT",—"' <br /> U3 SAN JOAQUIN LOCAL HEALTH DISTRICT 1 "' <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA v <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> i. (Complete in Triplicate) dV�, 5, <br /> r install the work <br /> . This <br /> cation is <br /> Application is hereby made n the San oo u n County Ordinance <br /> Ordinalnce No.549 for sewage or ealth District for a permit <br /> No. 1862 forcwell pump and the Rules and herein <br /> R Regulations of the San Joaquin <br /> made in compliance with San J q f N � <br /> Local Health District. rf <br /> City Lot Size PM <br /> Job Address <br /> 3 3 <br /> Owner's Name <br /> Address Phone <br /> Contractor <br /> Ad re �a- N- License IVo.I -./ t --Phone <br /> TYPE OF WELL/PUMP: ! NEW WELL 1-5WELL REPLACEMENT El DESTRUCTION ❑ 1 ; <br />` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE ; <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> GRICULTURE W Lam 'OTHER-WELtPITS/SUMPS <br /> INTENDED USE r TYPE OF WELL PROBLE REA C STRUCTION SPECIFICATIONS = <br /> ia, of Well Excavation Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca,. _ € �...� - <br /> "Type of Casing Specifications <br /> ❑ Domestic/Private !' ❑ Gravel Pack ❑ Tracy a .r Type of Grout <br /> ❑ Other E 1 Delta Depth of Grout Seal <br /> I Public .. :! rface Seal Installed 6y <br /> I I Irrigation II �._Approx. Depth I 1 Eastern <br /> Repair Work Done Ell of Pump P. State Work Done <br /> t Well Destruction ❑ Well Diameter Seialing Materia top 501 <br /> I` Depth Iller Material-(Below 50 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION _eNailabPelw thin 200 feetsysmrt�ed if public sewer is <br /> Installation will serve: Residence= Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water.table depth <br /> Character of soil to a deof 3 feet: <br /> e/Mf Capacity-71 <br /> pt No. Compartments <br /> SEPTIC TANK 'I ; TYP g <br /> s <br /> TREATMENT PMethod of Disposal <br /> �PKG. L .TElr <br /> ? Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1. ❑ No. & Length of lines Tota! length/size <br /> FILTER BED 1-1Distanceto nearest: Well y44Foundation Property Line ' <br /> Number <br /> SEEPAGE PITS Depth Size ---�- u—• +� <br /> Pra'ert Line... <br /> +SUMPS ^ ! �Disranca to�iearest: Well F 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 /> ( <br /> rules and regulations of the San Joaquin Local Health District. T <br /> f dome owner or licensed agent's signature certifies the following: 111 certify ihat'in the performance of the work for which this permit is issued, I shall not <br /> II 'employ any person in such manner as to become subject to workman's compensation laws,of California." Contractor's hiring or subcontracting 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 c for all required inspections Complete drawing on reverse side. <br /> Title: Date: . <br /> Signed X_.�^ v <br /> I � FDEPARTMENT USE ONLY <br /> Date Area 0 <br /> Application Accepted by <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ racy 835- 5 <br /> Applicant - Return all copies to:'tnvironmental Health Permit/Services 1601 E. Hazelton Ave- P.O. Box 2009, Stk., CA 01 <br /> Yf es` <br /> CK / I <br /> FEE AMOUNT RUE MOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO i <br /> ♦ EH 13.24 I REV.i/A 51 <br /> EH 14-28 <br />