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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> " 1601 Er HAZEL I ON AVE., STOCKTON, CA 9 <br /> Telephone (209) 466-6781 w <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ll the work herein <br /> .This <br /> cation is <br /> Application is hereby made I ance with Santhe San Joaquin Local Health JoaquinCounty Ordinance No.District49 for sewage or permit <br /> No. 1862 forcwell/pump atnd.he Rules and Regulations of he San'Joaquin <br /> ,., made in comp <br /> Local Heatth District.', 1t" <br /> Job Address City Lot Size�XZ= PM <br /> t.. <br /> AddressZ12Pfione <br /> Owner's Name _Iwaa <br /> '! ] IJ ! i <br /> Contractor <br /> Address (c ���aM&sr License No. Phone <br /> Zhll laf. Z <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION R_ <br /> PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER C3 <br /> DISTANCE TO NEAREST_: SEPTIC TANK SEWER LINES - D1.SPOSAL.FLD. PROP. LINE l <br /> FOUNDATION _ AGRICULTURE WELL . OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA j <br /> CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia:sof WA Excavation Dia. of Well Casing <br /> i <br /> El Domestic/Private F-1 Gravel Pack El Tracy 1 7ype,of..Ca ing � Specifications <br /> / r� r; .;❑ Delta ( Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx.: Depth ❑ Eastern i-Surface Seal Installed by - <br /> Repair Work Done El Type of Pump °" "1 H.P. State Work Done }, <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> 5- Depth- <br /> I _--4 Filler Material (Below 50'1 <br /> TYPE OF SEPTIC"WORK:``NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTI{UCTION ❑,(No septic system permitted 'rf public sewer�s <br /> "available within 200 feet.) <br /> Installation will serve: Residence Commercialr Other <br /> z - v - <br /> Number of living units: Number of bedrooms{ <br /> Water table depth <br /> Character of soil to a depth of 3 feet ' <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. LD Distance <br /> of Disposal <br /> Distance to'nearest: Well Foundation Property Line <br /> f � <br /> �-_ <br /> N_-o. & ngth-- T. en .h of lines Total length/size <br /> �'LEACFiING�LINE ❑ <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> E3 <br /> SEEPAGE PITS El �1 Depth Size Number ! <br /> SUMPS -[__1 Distancerto nearest: Well Foundation Property Line <br /> ii 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. ---- ' ' <br /> Homeowner or licensed agent's signature certifies the following:I'l.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 work man's compe sa <br /> tion laws of California." 1 <br /> The applicant must call for all required inspections. Complete drawing on reverse side. 1 <br /> Signed Title: p Date: <br /> S s" EPARTMENT USE ONLY <br /> Application Accepted by Date J �+ Area <br /> Date <br /> Pit Final Inspection by e <br /> Pit or Grout Inspection by, / <br /> Additional Comments: <br /> ❑ Stk 466.6761 ❑ Lodi 369-3621 ❑ Manteca-823-71 • "'❑ Trac 635-6385 <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 K �e RECEIVED_BY f DATE PERMIT'NO. <br /> INFO ,,ee <br /> + EH 13-24(REV.)/s 51 1ryD <br /> EH x4-28 <br />