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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> c 1601 E. HAZE43-ON AVE., STOCKTON-, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> work herein <br /> all the <br /> Application is hereby made to the San Joaquin Local <br /> d calnce No.District49 for sewage or permit <br /> 1862 for cwellldpump atnd the Rules and Reg <br /> ulatior�u^of the S.This pan Joaquin <br /> PP <br /> made in compliance with San Joaquin County <br /> Local Health District. PM <br /> �S City Lot Size <br /> Job Address 1� <br /> Phone <br /> U Address <br /> Owner's Name <br /> �yj bUJ1 ���� Lt>iL���� <br /> License No. / Phone <br /> Contractor WELL REPLACEMENT 113DESTRUCTION ❑ <br /> Address <br /> TYPE OF WELL/FU NEW WELL ❑ OTHER ❑ <br /> s REPAIR ❑ PROP. LINE <br /> PUMP INSTALLATION M R�AD1gpOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL SEWER LINES �� OTHER WELL PITS/SUMPS <br /> FOUNDATION _�� . <br /> ► INTENDED USE -TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ElMangy Manteca Dia. of Well Excavation Specifications <br /> ❑ Industrial ❑ Tracy Type of Casing <br /> El Domestic/Private ❑ Gravel Pack: Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Public Surface Seal Installed by <br /> ❑ irrigation �pprox. Depth ❑ Eastern H.P. State Work Done <br /> U FJv <br /> Repair Work Done ❑ Type of Pump' <br /> Well Destruction LlWell Diameter, <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 50'I <br /> + permitted 0 public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION ❑ aNailabpelwthine200 feet.) <br /> ( r 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: I j 5 }.Capacity_— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg r-a,��-%- . — .. " Method of Disposal .� <br /> PK[a. TREATMENT PLT. ❑ Foundation— Property Line <br /> Distance to nearest: Well �j' <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> Foundation C <br /> FILTER BED ❑ Distance to nearest:. Well--�--•� Y <br /> t <br /> iSize Number <br /> SEEPAGE PITS fl Depth property Line <br /> SUMPS �- <br /> ❑ Distance to nearest: Weil Foundation— <br /> ! <br /> DISPOSAL PONDS ❑ ! <br /> hereby certify that i have prepared this app)ication!and that the work will be done in accordance with San Joaquin county ordinances,state laws, an <br /> Home andrules reg la tions of the <br /> agent's Joaquin: <br /> oaq in: o cert es the following '=1 certify that in the performance of the work.for,which this permit is issued, I shall not <br /> signa <br /> 9 cert' that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the foliowing certify <br /> tion laws of California." I <br /> The applica s 11 r all r 11,ra it d inspections. Complete drawing on revers side. 06 <br /> 5 Date: <br /> Title: _ <br /> Signed <br /> FO �EpAk=RNT USE ONLY ` /f� <br /> Date D "^r Area (�/ <br /> Application Accepted by ie Iii - Date / <br /> Pit or Grout Inspection by <br /> 4 Date Final Inspection by — ---��--�� <br /> Additional Comments: _ ❑ Manteca 873-7144 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazahon Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMI-r NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 4R7 <br /> �IS 131 <br /> + EH 13-24(REV.4/851 <br /> EH 44-26 <br />