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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) <br /> .This <br /> madecation is <br /> inApplicationcompliance made <br /> Sanothe Joaquin n Joaquin county Ordinancealth No.District49 far sewage or No. 1862 fo well//pump and the Rul s and Rego ations of the Sans Joaqu n <br /> made in co p <br /> Local Health District. /�/� <br /> fs�S� lv Sd� S City Lot Size PM <br /> Job Address (/ <br /> Phone <br /> G�� G Address <br /> ' <br /> Owners Name / O G <br /> Contractor <br /> MtGLt Address License No. <br /> 0ne <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL <br /> SYSTEMCEMENI REPAIR ❑ DESTRUCTIONOTHER L7 U <br /> PUMP INSTALLATION 1-3 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public Q Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 .y <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ alvailablejwithin 200 festrtted if public sewefis <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity_�� <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> 4 <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines �0Property Line <br /> FILTER BED a Distance to nearest: Well X— Fo tion__� — <br /> I� SEEPAGE PITS �❑ Depth Size Number <br /> j ❑ Distance to nearest: Well Foundation Property Line <br /> SUMPS <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wiil 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 signature certifies the following: "I certify that in the performance of the work for which.this permit is issued, k shaft not <br /> g or sub-contracting <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring signature <br /> certifies the following:111 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 call f all requ. d inspecti . Complete drawing on reverse side. y 7� <br /> Signed Title: <br /> Date: <br /> �lv/ <br /> �jDR DEPARTMENT USE ONLY 7 <br /> Date ,2� -P7 Area <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> /Yj,�Ltrr �• ,, <br /> Additional Comments: ' ' <br /> ❑ Stk 466-8781 ❑ Lodi 369-3621 ❑ Manteca 823-7leA ❑Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-24(REV.1/e 51 � <br /> EH W28 <br />