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i <br /> S APPLICATION-FOR PERMIT 1, <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 /> is <br /> i' made i <br /> Application <br /> heteby <br /> made <br /> San Joaquithe n County d d nan Joaquin lncle No.549 for sewage or ealth District fo a permit <br /> No. 1862 forcwe111dpump install <br /> nd the Runes and herein <br /> Regulations of tlhe San Joaquin <br /> made in P .t <br /> Local Health District. <br /> # © City Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name z Address <br /> Contractor �-� ddress <br /> ?] License No. 363 .) Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 OTHER <br /> 1-3 <br /> � PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L1OTHER L] <br /> 44 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE5i DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca (Dia. of Wel! Excavation <br /> Type of Casing Specifications <br /> 11 Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Grout —' <br /> ❑ Other ❑ Delta Depth of Grout Seal yp <br /> {1 Public f - <br /> I I irrigation -Approx. Depth I 1 Eastern Surface Seal installed by <br /> H.P. State Work Done .— <br /> Repair Work Done ❑ Type of Pump O <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAIR/ADDITION i I DESTRUCTION i I (No septic systthinem #iitied if public sewer is <br /> available Installation will serve: Reincem <br /> ince ''comercial Other <br /> Number of living nsid Number of bedrC17ooms Water table depth ~ " ?� <br /> Character of soil to a depth of 3 feet: <br /> No. Compartments` '— <br /> SEPTIC TANK l ype/Mf9t a r <br /> Method ofspgsal <br /> PW-TREATMENT ❑ <br /> _-/ __,_ Property Line <br /> Distance to nearest:� Welk Foundation. t t <br /> LEACHING LINE mid'o. & Length of lines �Toial-lengthJsi' <br /> FILTER BED ❑ Distance to nearest: Well Foundation _2�od_ Property Line <br /> x <br /> I SEEPAGE PITS 1kl� 6epth f Size Number <br /> Property Line <br /> SUMPS C-1Distanceto nearest: Well Foundation [�.— p Y <br /> k DISPOSAL PONDS ❑ <br /> and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application <br /> I rules and regulations of the San Joaquin Local Health District. ssued, I shall not <br /> Home owner or licensed agent's signature certifies the fdllowing::'I-certify that in the performance of the work for which this permit is i <br /> k employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> Certifies the fallowing: "I certify that in the performance of.-the walk for <br /> which this permit-is issued,I shall employ persons subject to workman's compensa <br /> Z <br /> laws of California," <br /> app i mus call for require inspe ons. rowing on rey�rse side. <br /> ne <br /> Title (/` Dale: r/ <br /> FOR DEPARTMENT USE ONLY � 1� <br /> j Date Area <br /> i Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date a <br /> A ditionaI Comments: <br /> "— ' S[k 466-6781 ode 369-3621 - Manteca 4, 7104 - ❑Tracy '835 5 <br /> pplicant - Return all copies to: Environmental Helilth PermitlServices 1601 If. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffE <br /> AMOUNT DUE AMOUNT REMITTED 1 CASµ �'-RECEIVED BY GATE PERMIT h0. <br /> -�- — <br /> ._ _ <br /> a EH 11244REV.11x 51 .....r`�� <br /> EH 14-2e <br />