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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 /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 far well/pump and the Rules and Regulations of he S nliJoaquin <br /> Local Health District. <br /> Job Address n <br /> City Lot Size PM <br /> Owner's Name Address <br /> , Phone <br /> Contractor's Name /ADO (�j�}Tg� �g� <br /> L�--�� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION AZAA � DESTRUCTION E:�YSTEM REPAIR ❑ OTHER ❑ a1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -. <br /> DISPOSAL FLb, PROP. LINE <br /> FOUNDATION �._ - �<--- <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> AJDomestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of WeII as <br /> Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal { <br /> EJ Irrigation _q TYpe Grout <br /> '�"" pprox. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of1Pump ""1_. H. G D� <br /> � State Work Done <br /> Well Destruction ❑ Well Diameter iSealing Material (top 50') U <br /> p i asy9 <br /> De th i r Filler Material (Below 501) <br /> TYPE OF SEPTI- WORK: NEW INSTALLATION.❑ 'REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic y a <br /> ( E p system permitted if public sewer is �1 <br /> Installation will serve: 6sidence1 available within 200 feet.) <br /> Commerciali Other } <br /> Number of living units: Numberkof"bedrooms <br /> Character of soil to a depth of 31fee�'1`J — <br /> SEPTIC TANKi — Water table depth _ <br /> PKG. TREATMENT PLT/❑ Type/Mfg + - Capacity <br /> pacity No. Compartments <br /> I � <br /> Distance-to Method of Disposal j <br /> earest_ Well _' - 'Fou'ndation Property Line <br /> LEACHING LINE ❑ No. & Lie gth of lines{' <br /> FILTER BED Total length/size <br /> ❑ Distance to onniearest: Well Foundation Property Line ; <br /> SEEPAGE PITS ❑ Dep;h Size <br /> —` "SUMPS _ Number <br /> a❑"'distance Lo nearest: '"^"'WeV �"""=�� ^ <br /> Foundation "-- 2-"-PropertyLine <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 ithe Sar' Joaquin Local Health District. <br /> Home owner or licensed ageri{s,signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such marinerias to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"f ceri:4 that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." p` <br /> The applicant I or 1,1ronspections. Complete drawing on reverse ide.SignedTitle: L��Gf�1 � Date: _ �o �'7 1 <br /> FO PARTME T USE ONLY 1 vn <br /> Application Accepted by <br /> Date AreaPit or Grout Inspection by Date <br /> f }}' F' nspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 `❑ Lodi 369-3671 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton.Ave._ P.O. Box"2Q09, Stk., CA 95201 } <br /> FEE AMOUNT DUE {{ AMOUNT REMITTEDCK iV <br /> INFO Y CASH c RECEIVED_BY DATE PERMIT"NO. e <br /> + EH 13-24 1REV.10183) \ . <br /> EH 1428 , Q --'-- - -- - .- -- — - — - ---- /� -�3 f•., <br />