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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />{ 1601`-E,,H,AZEL7OW�NVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . <br /> 5 <br /> (Complete in Triplicate) _ <br /> ll the application is <br /> alth <br /> Application is hereby made <br /> t Joaquin the <br /> County Ordinance Local <br /> No D549 for sewage or istrict for a permitNo. <br /> 1862 for well//pump and he Rules and IRegulations of the San Joaquin <br /> ith made in compliance w <br /> Local Health District. / <br /> r r v L� 1 City 55"- <br /> Lot-SI PM. <br /> s <br /> Job Address / t <br /> - _ Phone <br /> Address <br /> Owner's N e _f /Z 3 � 6 <br /> License No.16 hone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: EW WELL,❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION r�L, . <br /> SEWER LINES r� <br /> DISTANCE TO NEAREST: SEPTIC, � DISPOSAL FLD. PROP. LINE <br /> j TANK' PITS/SUMPS <br /> FOUNDATION ��- <br /> AGRICULTURE WELL OTHER WELL <br /> t INTENDED USE `TYPE OF WELL � P,ROBLEM.AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E ❑ Ind ial d Open Bottom 1.111.Manteca Dia. of Well Excavation— Specifications <br /> j. F. Type of Casing <br /> omestic/Private ❑ Gravel Packs ❑ Tr�a,�cy Type of Grout <br /> ❑ other i V.11 <br /> El Depth,of,Grout Seal <br /> El Public Su lace Seal installed by <br /> ❑ Irrigation /�PRrox.'Dept '❑ Ea ern yir <br /> g ®/ is H.P. <br /> State Work Dane <br /> Repair Work Done Type of Pump <br /> Well Destruction ❑ Well Diameter _L_ Seating Material (top 50'} <br /> Depth /\` .Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCk <br /> TION ❑ available withne200 feet.) if public sewer is <br /> ICmmercial, Other �n <br /> Installation will serve: Residence Commercial� � v, <br /> I' Number of living units: Number.of bedrooms Water table depth <br /> k . <br /> Character of soil to a depth of 3 feet: � Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ Property Line <br /> . 'Distance to nearest: a Well Foundation , <br /> 1 <br /> I Total length I size <br /> LEACHING LINE El No. & Length of lines e Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: wellFoundation <br /> '- <br /> Size, Number <br /> SEEPAGE PITS O Depth <br /> SUMPS property Line <br /> } ❑ Distance to nearest: Well t Foundation <br /> DISPOSAL PONDS ❑ <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, an <br /> i rules and regulati t e ri Joaquin Local Health District. ' Y nature <br /> it is issued, <br /> 4 g..„ Ra -- <br /> Home owner icensed aent ra gas to b'e�come s the' �ta wn `an, _06 that in <br /> onflaws of CaV'rforn ehrformance,ofg ContractoNrrslhiring op sub-contracti gl�gall not <br /> employ an person in such _ rkl.for ich this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies a followi : 'I c , that in the perfor <br /> t <br /> tion la sof Californ Ing <br /> The plicant m, ll� 1 require Ins <br /> itle: <br /> Signe 14, , <br /> F FOR 91EfARTMENT USE ONLY <br /> Date <br /> ✓ Area <br /> Application Accepted b . ��� <br /> � "'oDate <br /> .'' Final Inspection by /�J. Date <br /> { _—�� <br /> Pit or Grout Inspection y <br /> i <br /> Additional Comments: <br /> f ❑ Stk 46"781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant.{Return all copies to: Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> l FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> -_EH 13-�41REV.1/957 S• �o .. <br />