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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for permit No. 18&2 forcwe I/d/or install and the the Ruleswork and Regulherein cribedd of the This Sanapplication <br /> Joaquin <br /> is <br /> made in compliance with San Joaquin cou6ty <br /> 1 Ordinance No.549 for sewage or <br /> Local Health District. <br /> Z7= <br /> City Lat Size PM <br /> Job Address 7 <br /> Owner's Name Address X�'L�� Phon <br /> Contractor ddres <br /> w fVw No!®Z29�Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i <br /> EI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing Specifications Q <br /> 1 }n Delta Depth of Grout Seal Typo of Grout_--- <br /> f'1 Public C Other . J^' <br /> •�} <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by - 6 <br /> Repair Work Done [3Type of Pump H.P. State Work Done_ N <br /> Well Destruction ❑ Well Diameter, Sealing Material (top 50'1 O <br /> Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:1 REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: -U44r_ Number of bedrooms i-- <br /> Character of soil to a depth of 3 feet: Water table depth A <br /> SEPTIC TANK ❑ Type/Mfg I Capacity— No. Compartments <br /> ElMethod of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well �Foundation Property Line <br /> LEACHING LINE No- & Length of lines tan Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundations — Property Line f� <br /> _ Number ��fE <br /> SEEPAGE PITS Depth .�-Size Ifr <br /> SUMPS Ll Distance-to nearest: WellZ� Foundation - Property Line,cs � <br /> DISPOSAL PONDS 0 3. rdinances, state laws, and <br /> 1 hereby certify that I have prepared this application and that the work will be done in a'cco'rdance with San Joaquin county o <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."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." I <br /> The applicant must call for all required i ns. Complete drawing on reverse side. <br /> Signed <br /> t t7 Date: <br /> Title: <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by Date ea <br /> Date Final Inspection Date <br /> Pit or Grout Inspection by } <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 G1 Mlanteca 523-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environ mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CK#t <br /> FEE ; <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RfiCEIVED BY DATE PERMIT'NO. <br /> ik f. <br /> E +.EH13.24MEv.,inW <br /> !!! EH 14-26 <br />