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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 /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED 7 <br /> (Complete in Triplicate) <br /> ne No,549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the <br /> Hwork herein described. This application is <br /> made in compliance with San Joaquin County ordina <br /> Local Health District. <br /> � City Lot Size � PM 1 <br /> Job Address K7 <br /> Phone \� <br /> al dress r"G3 <br /> Owner's Name � e <br /> ddress <br /> License N Phone <br /> Contractor { �' DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ! WELL REPLACEMENT ❑ <br /> '" SYSTEM REPAIR OTHER ❑ <br /> 1 ti PUMP. INSTALLATION ❑ PROP, LINE, <br /> SEPTIC SEWER LINES __�— DISPOSAL FLD. timet <br /> DIS7ANC6TO NEAREST: TANK �— OTHER WELLPITS/SUMPS <br /> — s— <br />'r FOUNDATION AGRICULTURE WELL <br /> 1 <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIDNS+ Dia. of Well Casing <br /> ❑ Open Bottom ❑ MantecManteca Dia. of Well Excavation , t (� <br /> ❑ Industrial Type of Casing{" i Specifications <br /> c. <br /> Domes#ic/Private ❑ Gravel Pack ❑ Tracy YP Type of rout <br /> ❑ Public <br /> ❑ Other ❑ Delta Depth of Grout Seal } ,4; 4 <br /> __—Approx. De th ❑ Eastern Surface Seal Installed by <br /> 173 Irrigation State Work Done ; <br /> H.P � <br /> Repair Work Done Type of Pump Material )top 50'1 <br /> �, Saa�ing Well Destruction ❑ DDeltDiameter �— Filler Material (Below 50'1 <br /> P rt <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ (No <br /> elwthin 200 feet.) if public Sewe�is <br /> Installation will serve: Residence— Commercial f Other <br /> .t <br /> � a_... <br /> Number of living units: Number of bedrooms 1 Water table depth <br /> Character of sail to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK EDType/Mfg r - " Method of-Disposal <br /> PKG. TREATMENT PLT. ❑ Line <br /> Distance to nearest: Well: Foundation Property <br /> i r Total len thlsizeVol- <br /> - <br /> g � <br /> LEACHING LINE ❑ No. & Length of lines "N r v' <br /> ,Foundation , '- :`Property <br /> Well Line <br /> ❑ Distance to nearest: - _ <br /> FILTER BED I K f , p " <br /> Number <br /> SEEPAGE PITS `Depth Size , ,,, <br /> Foundation ��°''- Property Line4' " <br /> L3 <br /> SUMPS ❑ 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. <br /> Home owner or licensed agent's as torbecome subject to woo kman's compensatfy that in ion laws oof Califorrnia."Contractor'swhich <br /> 'hiring or sub-contracting ls signashall ture <br /> employ any person in such manner <br /> that e work for which this permit is issued,1 shall employ persons sj ct to workman's compen <br /> sa- <br /> certifies the following:"I certify in the performance of th <br /> tion laws of California." <br /> The applicant us ca11 f all require in i s. Complete drawing on rev sided Date: <br /> Title: <br /> Signed <br /> FOR DEPA TMENT USE ONLY <br /> j Date �:. e• g""Area-- <br /> Application Accepted by Date : <br /> Dat_� Final Inspection by i <br /> Pit or Grout Inspection by i <br /> Additional Comments: ❑ Manteca 823 7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 . <br /> Stk., CA 9520 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5 J <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> C # RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> Q 1��3 �S 13or3 i <br /> +EH 18-24(REV.1/s 51 <br /> EH 14.26 <br />