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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT # <br /> 1601 E WAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) This application is <br /> Application is hereby made to the San Jo aqujn Local He No District for sewage or permit <br /> No. 1862 for we Ildpump and the Ruoles and(Regulations of the San Joaquin <br /> i <br /> Joaquin County Ordinanc <br /> made in compliance with San Joaq y� h <br /> Local Health District. Q PM <br /> 11111, 111r City V Size <br /> Lot <br /> Job Address 'T <br /> Phone <br /> V r Address <br /> Owner's Name A � <br /> O b License No. ?tone <br /> Contractor L' L Address DESTRUCTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT LJTYPE OF WELLIPUMP:., PUMP INSTALLATION <br /> ` SYSTEM REPAIR 13 DISPOSAL <br /> ❑ <br /> ❑ . DISPOSAL FLD. PROP. LINE <br /> SEWER LINES <br /> DISTANCE TO NEAREST: SEPTIC TANK " . OTHER WELL PITS/SUMPS <br /> FOUNDATION" f AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBL_EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifrcations <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> ❑ Domestic?Private 1 n Delta Depth of Grout Seal <br /> [l Public Cl Other <br /> Surface Seal Installed by <br /> I 1 Irrigation _Approx. Depth l i Eastern State Work Done <br /> Repair Work Done - L7 Type of Pump <br /> r H.P. I <br /> ' Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter `��_ <br /> Depth �1� - ' � `' �.�.Flller Materia! (Below 50'1 <br /> tic system permitted it public sewer is <br /> available within 200 feet.! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l:l R PAIR/ADQITIDN Li DESTRUCTION I ( ep <br /> Installation will serve: Residence - <br /> Number of living units: N,InberI bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: } . Capacity_ No. Compartments <br /> SEPTIC TANK' ❑ Type/Mfg L Method of Disposal <br /> PKG. TREATMENT PLT. d [ Foundation Property Line <br /> Distance to nearest: Well t <br /> S s <br /> c Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> Foundation i <br /> FILTER BED ❑ Distance to nearest: Well & <br /> I 7f <br /> r s Number <br /> SEEPAGE PITS i I Depth I Size_._ .- _ -.-_- - ` Line <br /> " ""- Foundation <br /> n t Prom` <br /> SUMPS ❑ Distance to nearest: Well a <br /> DISPOSAL PONDS' © '# <br /> I hereby certify that I have prepared this application and that the work will be done in ac�ordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. itwork for <br /> Home owner or licthis pefff <br /> ensed agent's s'gas to become sub eco following: <br /> wiorkman'srtaampensation ly that in the aew'soof Californi he Contractor'sthiring or sub-contracting signature <br /> ore <br /> 4 employ any person in such manna <br /> certifies the fallowing: u certify that s the performance of the work for which this permit i 1 issued, i shall employ persons subject to workman s compens <br /> do5 of California." <br /> The applic ust_ or-a req d-i ti Complete.drawing exerse_side. .- <br /> Date: <br /> Title: <br /> Sig � <br /> F DEPARTMENT USE ONLY <br /> -Date- Area- <br /> A lication Accepted by� _ ate <br /> PP _-. o ,., ti4 . 3 Final Inspection by D <br /> Pit or Grout Inspection by � _ <br /> Date—....��— <br /> Additional Comments: <br /> ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca- 823 7104 ❑ Tracy 835-6385 <br /> f <br /> 01 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Silk., CA 852 <br /> i <br /> r FEE AMOUNTIDUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO rg <br /> + EH 53-24(REV.1/n 51 <br /> d�3s <br /> EH 14-28 <br />