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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> w <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> f (Complete in Triplicate) ion is <br /> �ijin Local Health f r <br /> the w <br /> all <br /> Application is hereby made th Sin County Ordinance No. forD549 for sewage or istrict to <br /> 1862 for well/pump aconstruct an /ortnd the Rgles and'R gulations of the Sanl cati Joaquin <br /> te San Joe <br /> made in compliance with Sanq <br /> Local Health District'. <br /> e.fi^;, g, •t ,,. Lot Size .., _ PM <br /> City <br /> Job Address <br /> r <br /> Phone ' <br /> Owner's Name Address ,err <br /> ° 1 Phone r [3 <br /> Contractor <br /> ` Address -�ense No. <br /> NT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE CEMENT Ll <br /> INSTALLAT ❑ <br /> OTHER F]ION SYSTEM REPAIR a <br /> DISTANCE TO NEAREST:-SEPTIC,TANK <br /> SEWER LINES .��-- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ?ITS/SUMPS <br /> M AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLE <br /> I Dia. of Well Casing <br /> Dia. <br /> C3 Industrial ❑ Open Bottom ❑ Manteca Da. of Well Excavation ;Fy <br /> Type of Casing Specifications <br /> ,{3 Domestic/Private ❑ Gravel Pack _ ❑ Tracy �a <br /> ❑ Public ❑ Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> —Approx. Depth Eastern Surface al Installed by <br /> ❑ Irrigation tate Work Done F <br /> ` Type of Pump H.P. <br /> Repair Work Done r <br /> Well Destruction ❑ \ ell Diameter <br /> Sealing Material [top 50'! <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW 1N5TALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ availabil w t(No septic hine200 feet.led if public sewer is <br /> r !0 <br /> Installation will serve: Residence r� Commercial� Other <br /> Number of living units: I: �Number of bedrooms <br /> Water table depth <br /> Character of soil.to a depthf feed Capacity�*� No. Compartments <br /> SEPTIC TANK ❑ TypelMfg �4. Method of Disposal <br /> PKG. TREATMENT PLT. ❑ } 1s <br /> Foundation Property Line. <br /> distance to nearest: Well k <br /> Total length/size I <br /> LEACHING LINE_. ❑ No. & Length of lines <br /> 7 I Foundation Property Line <br /> FILTER BED ❑ Distanceto"nearest;'yy> Well e,F } <br /> r ❑ Depth ' Size <"• ° �" Number <br /> SEEPAGE PITS s Property-tine ' <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> _ F - ._. .'f <br /> DISPOSAL PONDS ❑ <br /> I ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 hereby certify that i have prepared this application and that the work w <br /> rules and regulations of the San Joaquin Local Health District. Iork for <br /> r Home owner a slicensed uch manne gas tore certifies the following: "I certify that in the become subject to workman's compensation laewsoof California," Contractor's g1 or sub contract ng signature <br /> employ y p <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to.workman s compensa <br /> tion laws of California." <br /> The applicant m t call fo r uired inspections. Complete drawing on se side. <br /> _ _ <br /> Title; ^ Date: <br /> Signed 7(—yam, - I �� Y r' <br /> I FOR DEPARTMENT USE ONLY <br /> Date Area'"' - <br /> Application Accepted by <br /> Date Final Inspection by r � Date Lr✓-- <br /> Pit or Grout Inspection by fir; i <br /> Additional Comments: k. G <br /> ❑ Stk 466-6781 ❑ Lodi 3693621 Manteca 823-7104 ❑ Tracy 835 6365 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA95201 <br /> PERMIT`�' <br /> FEE NO'{" <br /> PATE <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO - <br /> � EH 13-24(REV.I-/$5) <br /> I-1�, coo Swig C ��`t s Fs5-ti�tie <br /> EH W26 <br />