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APPLICATION.FOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> -Telephone (209) 466-6781 <br /> i _ F <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> { (Complete:in Triplicate) application is <br /> ' <br /> Application is hereby made to the u nnJoaquin Local Health County Ordinance No.District99 for sewage permit to <br /> .. 1862 for wellIpump end the Rules and Reg Nations of the San Joaquin <br /> made in compliance with San-Joaquin 'oI ,5 <br /> wt <br /> Local Health District. a <br /> P1 City <br /> Lot Size PM <br /> Job Address <br /> Phone <br /> Address f <br /> Owner's Name <br /> /��VxS ire "'I– License No.�-----Phone_ <br />` Contractor 1h a Wa Addres`s DES 11:1 ON 11NEW�WELL ❑ WELL REPLACEMENT ❑ <br /> k TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER C1PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> '' SEWER LINES ,_�- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �— AGRICULTURE WELL OTHER WELL <br /> FOUNDATION \ <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca . . Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Industrial Type of Casing Specifications <br /> ❑ Domestic!Private ❑ ❑ Tracy Gravel Pack � Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> F] Public Surface Seal Installed-by <br /> ❑ Irrigation �pprox. Depth ❑ Eastern State Work Done <br /> Type of Pump <br /> H.P. <br /> Repair Work Done E3TYP Sealing Material flop 501 . <br /> ' Well Destruction ❑ Well Diameter <br /> r Depth r Filler Material {Below 501 <br /> available within 200 feet.} <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION L3DESTRUCTION Wo septic system permitted if public sewer is <br /> 1Commercial -------- <br /> Installation will serve: Residen*e Other� # - <br /> Number of living units: Number'of bedrooms _ 9 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. ❑ Foundation Property tine x <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. &�Length of lines Property Line <br /> I . <br /> Foundation- <br /> FILTER BED ❑ Distance to nearest: Well <br /> � Size � Number <br /> SEEPAGE PITS [I Dept Property Line <br /> rx -M– "Foundation-'— ' <br /> SUMPS r ❑ Distance to nearest: Well <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 <br /> l not <br /> Home owner or licensed agent's signature some subject Ilowing: "I to workman'sify that in the lawsoof California." Contractor's or sub-contracting this permit is issued, l signature <br /> employl employ any person in such manner as to be t <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 compen _ <br /> tion laws of California." <br /> The applicant must call forAl required inspections. Complete drawing on�erse side. Date: <br /> Title: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date r� b Area ` <br /> t Application Accepted_by U /_1 Date <br /> e Fin I Inspection by {a ago <br /> - Date�1 <br /> 1 Pit or Grout Inspection by r , �ry ,moi �t✓7 <br /> 6 Additional Comments: !` <br /> ❑ Stk 466-6781 ❑ Lodi )W 1 [IMant ca .823-7104 ❑ Tracy 835 <br /> ` Applicant Return all copies to: Hazelton Ave.,.P.O. Box 2009. 5tk., CA 95201 <br /> Environmental Health Permit/Services 1601 E. <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT,DUE AMOUNT REMITTED <br /> CA <br /> INFO <br /> + EH 13-24'1REV.1/8 5) _ <br /> EH 14-28 ,s. t ,. ...,, -. ,.. .-.�.�.f.•.�..-. ..,. - <br />