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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-1 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ,. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> .,(Complete-in.Triplicate) <br /> .3 <br /> all theworapplication is <br /> Application is hereby made Joe Joaquin Jo Couaquin nty Ordinance No:Health 549 for sewage permitistrict for a No 1862 forcweu1pump and the Rules and IR Regulations of he San Joaquin <br /> made in compliance with Sanq , <br /> Local Health District. Z� <br /> PM <br /> Job Address <br /> 7� <br /> I l7 t�0 City � f �rLot Size <br /> !7 J p C3 G rJ/ <br /> Phone O fQ <br /> J`C Address <br /> Owner's Name <br /> License No. Phone r <br /> _—. --- -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTfl <br /> Contractor Address RUCTION a L\v <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> .FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom 0 Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> r ❑ Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing Depth of Grout Seal Type of Grout <br /> ❑ Public El Other ❑ Delta <br /> ❑ irrigation ---Approx. Depth El Eastern <br /> Surface Seal Installed by <br /> H P State Work Done — <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 - <br /> Well Destruction ❑ Well Diameter 4 <br /> 'Depth Filler Material (Below 501 <br /> Y!, <br /> POF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ DI ❑ DESTRUCTION (No <br /> ailabpelwithinie200 feet.) if public sewer is <br /> I Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth 1 <br /> Character of soil to a depth of 3 feet: f Capacity No. Compartments <br /> I SEPTIC TANK ❑ 'Type/Mfg 4 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ . r <br /> Distance to nearest: - Well <br /> r Foundation Property Line <br /> ' Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED <br /> ❑': Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS ❑ Depth <br /> SUMPS ❑,k Distance to nearest: Well <br /> Foundation �Property tine . <br /> DISPOSAL PONDS ❑ <br /> 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 /> I <br /> rules and regulations of the San Joaquin Local Health following: certify <br /> that in the work for <br /> Home owner or licensed agent's <br /> n such manner torbecome subject workman's compensation laws sof Californ ahe Contract�srh i ng op sub conitract ngl signature <br /> employ any person persons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permits issued,I shall employ p I <br /> tion laws of California." <br /> The applica ust call for all requir d in ctions. Complete drawing on reverse side.. '_� <br /> pe <br /> Title: Date: <br /> Signed - <br /> FOR DEPARTMENT USE ONLY D <br /> Date 'r!� Area <br /> Application Accepted by � <br /> ` Final Inspection by Date <br /> Pit or Grout Inspection by Date j04�� <br /> r <br /> Additional Comments: W r18�Lt Se W�5 'fit e r <br /> _ EIStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835 6385 Stk., CA 96201 aZf0 i-A 1.7 <br /> Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave., P.O.:Box 2009. D ��, <br /> RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH { <br /> 7 <br /> i EH 13-24(REV. <br /> EH 14-26 <br />