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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ;. Telephone (209) 466-6781 <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora the r <br /> k herein described. This r made in compliance with San Joaquin County Ordinance No.549 for sewage No. 18&2 for cwell and/or <br /> and)the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> city Lot Size �J�4 PM <br /> Owner's Name Address '!. <br /> i f PhL one <br /> ��ContractorJ � - � Address (JC f� <br /> TYPE OF WELL/PUMP: License No_—O Phone 0 �3� <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ..PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ 1 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE \ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS 1 <br /> INTENDED USE ^TYPE OF'WELL- ­PROBLEMAREA' CONSTRUCTION SPECIFICATIONS J <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ED Gravel Trac <br /> Gravel Pack Dia. of Well Casing <br /> y Type of Casing Specifications <br /> ❑ Public ❑ Other - ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx.;Depth ❑ Eastern Type of Grout <br /> 1 Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H P <br /> Well Destruction C] Well diameter State Work Done <br /> Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION ReREPAIR/ADDITION ❑ DESTRUCTION ❑ (No tic <br /> .yam se P system <br /> permitted if public sewer is <br /> Installation will serve: Residence Commercial Other/Z available within 200 feet.) <br /> / <br /> Number of living units:-_ Number bedrooms fyf <br /> Character of soil to a depth of 3 feet: i <br /> SEPTIC TANK Water table depth 01 <br /> �' Type/M#g - 4� Capacity No. Compartments <br /> PKG. TREATMENT PLT. L] <br /> Method of Disposal <br /> Distance to;nearest: Well 1p7�, Foundation pro r <br /> ) party Line <br /> LEACHING LINE LzY No. & Length of lines _ r <br /> Total length/size t <br /> FILTER BED ❑ Distance to�nearest:. Well 1 <br /> Foundations property Line ± <br /> k <br /> SEEPAGE PITS ❑ Depth t-; Size <br /> SUMPS Number <br /> 0.- ❑ Distance to nearest: Well -Foundation <br /> DISPOSAL PONDS C1Property Line <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 the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: � ` <br /> em to an g: "I certify that in the performance of the work for which this permit is issued, I shall not t <br /> p Y Y person in such manner as to become subject to workman's compensation laws of'Cafdornia."Contractor's hiring or sub-contracting signature <br /> tion'laws offCalifornia.-lI certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> X'7, <br /> The applicant must call for all required inspections-. Complete drawing on reverse side. <br /> Signed ,t)4 ' ` - �y I <br /> Title: Date: 6 1 <br /> tei f FOR DEPARTMENT USE ONLY <br /> Application Accepted by J Date `^ '�' •/ <br /> Area <br /> Pit or Grout Inspection by Date Final inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant- Return all copies to: Environmerttal Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Z W, Stk., CA 952b1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK c <br /> INFO CASH RECEIVED BY DATE PERMIT N0, <br /> + EH 13-24(REV.1/05) <br /> EN 1426 / <br /> r <br /> / I <br /> (P <br /> t <br />