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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZE=L T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 { <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 4 <br /> all the work herein dascribe& <br /> 6tion is <br /> Application is hereby made to the San Joaquin Locants No.District Health549 for sewage or permit <br /> 1862 for well pump aor tnd the Rules and Regulations of he San Joaquin <br /> made in compliance with San Joaquin County <br /> 4 + <br /> Local Health District. ; <br /> ]� A FSt'►�la 1. ' <br /> Job Address <br /> 0 wo� lfClv�S l��`'1`(/ Citi, 7_-Lot Size a. PM <br /> -�-� _ __ - <br /> r' " � � I T:-.'Address^ Phone <br /> Owner's Name <br /> Phone <br /> Contractor's Name a C ��- License No. L13 <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL.FLD_.,__. _�RQP• LINE r <br /> DISTANCE TO NEAREST: TIC TANK PITS/SUMPS a <br /> FOUND AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL BLEM AREA CONS RT UCTION SPECIFICATION$; _-- t. <br /> El Bottom © Manteca Dia. of Well. Excavation I Dia. of Well Casing <br /> ❑ Industrial i Specifications <br /> ❑ ----- <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy T�7pe_of -Casing <br /> ❑ Public ❑ Other CJD t <br /> Depth of Giroutj epl type <br /> ❑ Irrigation ---Approx. DepthSurface Seal installed b <br /> ❑ Eastern by. - � <br /> H P �% State Work Dane <br /> Repair Work Done Type of Pu f <br /> r Sealing Material (top 50') <br /> i <br /> Well Destruction "0. Well D' eter Filler Material SBelow 501 <br /> -�Dept <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION Elavailable�witseptc h ne200-feettted.if public sewer.is o <br /> Installation vol serve`. 'Residence Commercial Other - <br /> .. <br /> Number of living units:. Number of bejlrooms --Water table depth <br /> Character of soil to a depth of 3 feet: r; No. Compartrmnts <br /> Capaclty� <br /> SEPTIC TANK ;❑ Type/Mfg Method of Disposal <br /> ENT PLT. ❑ � -•- -.• ��`" <br /> PKG. TREATMENT Property Line <br /> Distance to nearest: Well Foundation�"'�"'"— <br /> I *' "* .1 1. h y,, <br /> ,'fid 1 <br /> No. & Length of lines Total length/size <br /> ,. LEACHING LINE Property_Cirle� <br /> FILTER BED © Distance to nearest: Well Foundation <br /> Number <br /> SEEPAGE PITS a❑ Depth Size ' <br /> `7 f �-''-.— Prop rh+ Line <br /> SUMPS Distance to nearest: Well [ � Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with S n Jnalauin county ordinances stave laws, and V� <br /> rules and regulations of the San Joaquin Local Health District. ork for r' <br /> Home owner or licensed agent's signature certifies the following: <br /> workman's compensation Ithat in the sewsoof Califormance rnia a ontract rs�h r nge o�sub cant actnglsigniatuore ' <br /> ` employ any person in such manner as to become subject rsons subject to workman's compecsa <br /> certifies the following:"�ertify that in the performance of the work for which this permit is issued,I shall eci�ploy.pe $ <br /> tion laws of Californi f � <br /> 11y 2- <br /> The applicant mu all r all requir d ins ctions. Complete drawing on re rse side. . / �Ir <br /> 9 --tett/i�CC��/-/-�e''""����e"'"""••. --- —.Date: i <br /> ,/ Title: <br /> Signed } g <br /> FOR DEPARTMENT USE ONLY <br /> Date Area l/ <br /> Application Accepted by <br /> Date -Final.inspection by <br /> Pit or Grout Inspection by <br /> a <br /> 4.j >�1 4 D T L E n.a a-— I F <br /> Additional Comments: 83c54385 f' ' <br /> ❑ Stk 4666781 C1 Lodi 369 3621 ❑ Manteca 7104 ❑ Tracy ;CA-95201 f <br /> • Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE r�' jPERMEITO] <br /> 1NF0 2r_-�y+EH 13-24 1REV.101831 7`d� <br /> T- <br /> EH W26 -- - <br />