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PERMIT <br /> SAN <br /> - APPLICATION FOR <br /> l r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> f Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br />. + (Complete in Triplicate) <br /> /or install the work <br /> cation is <br /> madeC n(compliance with Sano the Joaqu nnCounty Ordinance Nuin Local Heto. 549 for sewage or h District for a permit <br /> No 1862 forcwell//pump and the Runes and 1R gulations of This <br /> he San r Joaquin <br />} Local Health District. <br /> r 7 City�� — Lot Size � PM <br /> y Job Address L S <br /> ��' I�T �• "' Phone <br /> Owner's Name Address f !1�qo 0 Q p, <br /> Contractor <br /> �Q Address J License No. PhonelV(01 <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. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 9INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing 'Specifications <br /> ElDomestic/Private- 1-1GravelPack ❑ Tracy Type e of Grout <br /> ❑ Public L1 Other ❑ Delta Depth of Grout Seal <br /> I Irrigation —..Approx. Depth I 1 Eastern Surface Seal Installed by <br /> i H P State Work Done <br /> Repair Work Done L1 Type of Pump — <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION i-I DE STRUCTION I avlailablelwthine200 feet)tied it public sewer is <br /> Installation will serve: Residence 4 Commercial— Other <br /> Other <br /> i - <br /> Number of living units: _ Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> C <br /> SEPTIC TANK YP T el Mfg —CICapacity No. Compartments <br /> PKG. TREATMENT PLT- Method of Disposal <br /> r { <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size— <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> r DISPOSAL PONDS ❑ 1 <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. no <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 ur <br /> 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 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." <br /> The applicant ust call for all required inspections. Complete drawing oCn�reverse sidle. <br /> M� ,yQ.G�— .Title: `1txLYnR�11�' _ Date: <br /> Signed )s '.�--� - <br /> OR DEPARTMENT USE ONLY <br /> Date 9A Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments; <br /> LJ Stk 466-67811 �3693621C1nteca 823-7104 ❑ 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 /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT RUE AMOUNT REMITTED CASH <br /> s _ <br /> + + EH 53-24 IREV. �� <br /> i EH 14-2e <br />