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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)ct and/or install the work herein <br /> Application is heieby <br /> th Sato he n Joaqu nn County Joaquin Olydinalnce Nto.549 for sewage or h District for a iNo. 1862 for well pump and the Rules and Regulations of Thisapplication <br /> San l Joaquin <br /> F, made in compliance w <br /> Local Health District. <br /> IJL City Lot Size PM <br /> Job Address ` i 'W 9 C <br /> I I F 1 14 110L, �• Phone <br /> o <br /> t Address �2a4L`{ ' �� ry�17 9lrb <br /> Owner's Name'�'d f <br /> �f icense No. X33?83 -Phone tea <br /> �t.l Address t <br /> Contractor lA`�QIWI/ <br /> NEW WELL WELL REPLACEMENT d DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: ��, SYSTEM REPAIR O OTHERyl� r� ' <br /> PUMP INSTALLATION ❑ <br /> I DISTANCE TO NEAREST: SEPTIC TANK - ���/ <br /> SEWER LINES -��— DISPOSAL FLD. PROP. LINE <br /> ; FOUNDATION AGRICULTURE WELL OTHER WELL_��s� PITS/SUMPS <br /> i INTENDED USE jITYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " V t <br /> h. Dia. of Well Casing <br /> ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> "Pte y Type of Casing /.� <br /> f Gravel Pack ❑ Tracy yp Type of Grout <br /> k Cl Delta Depth of Grout Seal <br /> k'l Public I� Other _ L/1 <br /> r• <br /> 4 I Irrigation (*a Approx. Depth l I Eastern Surface Seal Installs Y <br /> i <br /> { H.P. <br /> State Work Done <br /> Repair Work Done Q Type of Pump <br /> Well Destruction ElWell Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: 1NEW INSTALLATION l 1 REPAIR/ADDITION I f DESTRUCTION i I availablelc system permed wthin 200 feet if public sewer is <br /> k Installation will serve: residence_ Commercial— -Other <br /> Number of living units: .��I Number o1 bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑i Type/Mfg <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Q <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> I FILTER BED U Distance to nearest: Well Foundation Property Line <br /> IM. � <br /> SEEPAGE PITS l'fl Depth Size Number <br /> SUMPS C[l Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDSO <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, a <br /> rules and regulations of I an Joaquin Local Health District. <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 not <br /> signature <br /> employ any person'in such manner as to become subject to workman's compensation taws of California." ploy cersonsrsub ct t workman's ring or gcompensa- <br /> certifies the following: ,I certify that in the performance of the wok for which this permit is issued, I shalt employ p 1 <br /> tion laws of California." I. <br /> The applicant must call for all required inspe tions. mplete drawing on reverse side. <br /> Title: <br /> i Signed X i <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by. <br /> Date <br /> Date <br /> �final Inspection by Date <br /> Pit or Grout Inspection byilf <br /> Additional Comments: 11 <br /> 11Stk 466-6781 0 Lodi 369-3621 ❑ Manteca 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 /> 11 <br /> ` RECEIVED BY DATE PERMIT'No. <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED ASH <br /> + EH 13.24[REV.i 5Y 1p1 <br /> EH 1I-28 <br /> 63 <br /> �� I <br />