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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 ISSUED <br /> (Complete in Triplicate) ion is <br /> n described.This <br /> cal <br /> Application is hereby NrT1h San JoaquinSan <br /> Joalth District for a per <br /> ungty O dinauin lnce No.549 for sewage or <br /> mit <br /> No. 1862 for cwellldpump install <br /> nd the Rules and IR Regulations of the San s Joaquin <br /> made in compliance �O �� � G1�. <br /> Local Health District f =( o•-�� f��v��` <br /> IWA&AE City Lot Size c� PM <br /> Job Address �� <br /> Pho <br /> Owner's Name <br /> ti ,�1/ate l�P.ac�i_ f7/Gi _ Address <br /> �, <br /> Contractor 1 - Address <br /> S; ~� � tcense Nor�2 4 Phond� i. <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />° PUMP INSTALLATION <br /> SYSTEM REPAIR D OTHER C3 <br /> SEWER LINES DISPOSAL fLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � 1TS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> © Oen BottomManteca Dia. of Well Excavation <br /> I] Industrial P Specifications _ <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal �� Type of Grout S '� <br /> 1 LPublic n Other Ll Delta <br /> k -4176-Approx. Depth l 1 Eastern Surface Seal Installed by <br /> I I Irrigation State Work Done 1� <br /> Repair Work Done ❑ Type of Pump H.P. <br /> ' <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 50'1 —� <br /> perm <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION ( I DESTRUCTION I I (No sep7stetedil` <br /> system <br /> in feet.) if public sewer is <br /> Installation will serve: Residence_ Commercial_.� Other <br /> Number of living units: Number of bedrooms Wh <br /> Character of soil to a depth of 3 feet: Nis <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> MsalPKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation PropertLEACHING LINE ❑ No. & Length of linesTotal length/si <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS 11 Distance to nearest: Well Foundation Property Line . <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. „ ... permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following..-.3;6eitity that in'-the..performance of the work for which this <br /> such to become subject to workman's.compensation:la`ws.of California." Contractor's hiring or sub-contracting signatu <br /> employ any person in manner are <br /> ce of the'worOor'which this permit is'issued,I shall employ persons subject to workman's compensa- <br /> certifies the following: certify that s the performan <br /> tion laws of 'fomia" <br /> The appitc us c I r all r red inspections. Complete drawing on v rse std . <br /> • Signed <br /> Title: Date: <br /> FO DEPARTMENT USE ONLY <br /> Date r 0 Area <br /> Application Accepted by <br /> Pito Grou Inspection b <br /> Date Final Inspection by d Dat f <br /> t- <br /> Additional Comments: <br /> ❑ Stk 466-6781 di 369 362 Manteca 823-7104 #] Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> I. <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED LASH <br /> INFO 4/ �, Q <br /> ..EH 13-24(Rl:V.1/n5) _�� �' �a �10 �L <br /> EH 14-26 <br />