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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT YMENT <br /> 466-6781 <br /> �,1���04iON AVE , STOCKTON, (a <br /> CEIVE® <br /> (�Un►'a Hpp, riril.'C '"'til'IS�OXPIRES 1 YEAR Telephone IF OM DATE IS Tni- <br /> C 0 4 1989 <br /> ®AQ p,L SEAN JOAQUIN COUNTY <br /> � g4NM 1'! (Complete in Triplicate) LIC HE T <br /> { <br /> _S <br /> is �by'kllade the San Joaquin Local Health District for a permit to construct and/or install the work 6A}I�kR �A <br /> made a comp rico with San Jadgwn Cowry Ordinance No 549 for sewage or Na 1862 for welllpump and the Auies and Regulations o <br /> Local Health District 1®3 �� <br /> Job Address CitySj-+ ! of Size PM <br /> j��pfw;.ec G Phone �-32.2_ <br /> Owner s Name �+r.Address I 41c S <br /> 0- TO TO 2- Phone Q7Z"s 5 6 U <br /> Contractor Pfd Md Ltce <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST SEPTIC TANK SEWER LINES <br /> _ DISPOSAL FLD PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ¢ ., <br /> Dia of Wel! Casing <br /> ❑ Industrial C! Open Bottom IT Manteca Dia of Well Excavation _ Dia of Well s <br /> LZ Domestic IPrivate Gravel Pack ❑ Tracy Type of Casing_ <br /> I I Public 1 01110 / <br /> f fl Delta Depth of Grout Seal Type of Grout N <br /> I I Irsiodtion __ Approx Depth/tel I Eastern Surface Seal Installed by C <br /> Repair Work Done 0 Type of Pump /✓�i — H P State Work pone <br /> Well Destruction © Well Diameter Sealing Material atop 50 I <br /> /� �ur,;� Depth =SD 6 A 11 - ._ Filler Material (Below 56 i <br /> TYPE OF SEPTIC WORK NEW INSTALLATION i I REPAIR/ADDITION l k DESTRUCTION I 1 availabeic sybaern wthin 200 leett�` d d public sew[tr is <br /> Installation will serve Residence _ Commercial _ Other <br /> Number of Irving units Number of bedrooms I <br /> Water table depth <br /> Character of soil to a depth of 3 feet <br /> Ca <br /> SEPTIC TANK ❑ Type/Mfg pacity No Compartments <br /> PKG TREATMENT PLT ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> 1 <br /> LEACHING LINE Cl No 8 Length of lines <br /> Total length/size <br /> FILTER BED LI Distance to nearest Well Foundation Property Line E <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest Well Foundation Property Line <br /> z <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 slate laws and <br /> rules and regulations of the San Joaquin Local Health Diiltrict <br /> Home owner or licensed agent s signature certifies the following I certify that in the performance of the work for which this parrtut 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 of sub-contracting signature <br /> certilies the following I certify that in the performance the work for which this permit is issued I shall employ persons subject to workman s compensa <br /> tion laws of California ' , <br /> The applicant must cal{ for uired ins Clio Complete drawing on rev a si <br /> Signed X <br /> Ttls Date <br /> DE ENT USE NLY <br /> Date/ Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments <br /> ❑ Stk 466 6781 ❑ Lodi 369 3621 ❑ Manteca 823 7144 ❑ Tracy B35 G385 <br /> Applicant Return all copies to Environmental Health Permit/Services 1601 E Hazelton Ave , 3 0 Box 2009, Stk , CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> 0-5 1 L�5 _Z_�? <br /> . EH 13.24 IREV „ngi �Ov <br /> EH 14 25 <br /> 1 <br />