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ii <br /> i• APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Ld 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> f�r PERMIT EXPIRES 1 YEAR FROM DATE:ISSUED <br /> 1Camplete in Triplicate) <br /> cri <br /> madecation is <br /> i is is*Ubyemade to lthe'Zn Joaquin Ordinance nalHealth nce No.District549 for sewage or permit <br /> No. 1862 forcwell/pump and the Rules andall the work 'Regu ations of he San:This g Joaquin <br /> made in compliance with San Joaquin County ��� � �/' r <br /> � <br /> Local Health District. � /t"�„�, ` 1; ,� E ,� <br /> �, /"V City_ Lot Size P <br /> Job Address 44 <br /> Address ne <br /> Owner's Name <br /> ,s - �� -` �' =� rh` Phone v rVU►� <br /> Contractor's Name icense No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION LJ <br /> PUMP INSTALLATION F1SYSTEM REPAIR El OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL,FLD.}�� PROP. LINE O , <br /> .FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing W <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications LL <br /> ❑ Domestic/Private. ❑ Gravel Pack ❑ Tracy Type of Casing L'kt <br /> ❑ Public ElOther <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H P a State Work Done f 4 <br /> Repair Work Done [I Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑• DESTRUCTION ❑ aNO septic sy tem rmitlted if public sewer is , <br /> r Installation will serve: Residence commercial_ Other n <br /> L Number of living units:�. <br /> Number of bedrooms -, Water table'depth ` <br /> Cfiaracterof soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg — Capacity <br /> l ! Method of Disposal <br /> „PKG. TREATMENT PLT. ❑ f <br /> Distance to nearest: Well Foundation!.tQ' Property Line <br /> j No. & Len th of lines Total lengthlsize <br /> LEACHING LINE g f t Property Line f <br /> FILTER SED j� Distance to nearest: Well — Foundation W P rty — <br /> Size Nymber <br /> Depth <br /> SEEPAGE PITS Property Line — f <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ € <br /> 1. 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 Locai 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." Contractors hiring or sub-contracting signature yt F <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 st � r uire s tions. Complete rowing on side. . <br /> Date: <br /> Signed <br /> Title: <br /> FOR DEPART NT USE ONLY <br /> Da rea <br /> Application Accepted by � � �-- <br /> / X Final Inspection by Date�� <br /> it r Grout Inspection by Date L�— ; <br /> 7�dditional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED 9Y DATE PERMIT•'N0. <br /> LINFO AMOUNT DUE AMOUNT REMITTED GASH <br /> + EH 13-24(REV.10153) �� <br /> EH 14-25 <br />