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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 11'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein <br /> . This <br /> Applicacation is <br /> tion is ante with SanoJoaqu'n Counthe San ty Ordinance No.549 for sewage or uin Local Health District for a permit <br /> No. 1862 for owell/dpump and the Rules and Regulations of the San l Joaquin <br /> made in comp <br /> Local Health District. ( � v � CJ ✓ 7'C. <br /> t Z. <br /> 4 r City ri Lot Size 11 PNI : <br /> Job Address 0 <br /> e Address � O Phone �Q <br /> Owner's Name �' I�a1111.4 <br /> 0-Y2- <br /> f �p�d License No. Phone <br /> Contractor L��L Address r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME Q <br /> DESTRUCTION ❑ �[/� e ®� <br /> P © SYSTEM REPAIR ❑ <br /> OTHER <br /> UMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE %a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF'WELE ' 'PROBLEM AREA y'CONSTRUCTION SPECIFICATIONS Dia. 04 Well Casing <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> El Domestic/Private P.Gravel Pack LJ Tracy yp Type of Grout - <br /> i I Public Cl Other ❑ Delta Depth of Grout Seal <br /> Approx. De h l I Eastern Surface Seal Installed by <br /> Irrigation (i4 ,r le.ro�l afr�`�°%ir1 4 'L <br /> L{ H P State Workone 7' _ <br /> Repair Work Done ❑ Type of Pump P (ate <br /> Weil Destruction ❑ W611 Diameter 40s! Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION l I (No septilablec systthinem <br /> rmiitted if public sewer is <br /> avaeet <br /> Installation will serve: Residence Commercial Other <br /> Number of giving.units: Number of bedrooms <br /> Water table-de{ith~ <br /> Character of soil to a depth of 3 Cap <br /> feet''�^- - -__- y <br /> �«---,-.—�•-�-- <br /> acity 5- No. Compartments <br /> SEPTIC TANK D Type/Mfg <br /> Method of Disposal <br /> PKG.`TREATMENT PLT. ❑ <br /> i Distance to nearest: Well Foundation Property Line <br />� f _ <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 'a L3 Distance to nearest: Well Foundation Property Line <br /> F SEEPAGE PITS P I Depth Size Number <br /> SUMPS ❑, 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 (t <br /> rules and regulations of the San Joaquin Local Health District. 1�DD <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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <br /> certifies the following:"I certify 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." 4 <br /> The applicantmu ca fo . ti requir n ons. Complete drawing on reverse side. ��Ci � <br /> I Title: Date: <br /> Signed <br /> R DEPARTMEN USE ONLY <br /> Area © Q <br /> Application Accepted by `M"�' �'` ^k" Date <br /> pate YTS Final Inspection by Date <br /> Pit or Grout inspection by , <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 El Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r - <br /> 1 ' FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> i.EH 13-241REV.ti851 efl <br /> EH 14-28 <br /> j <br />