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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone.(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 4 � ealth District for a p application is <br /> Application is he+eby made to the San Joaquin0 nalnda No.549 for sewage or'No. 1862 for cwellldpuomp and.the Rules and hereininstall the work R Regulations of Thishhe San Joaquin <br /> made in compliance with San Joaquin County / <br /> Local Health District. , <br /> fGit <br /> _ et?oi Size PM <br /> Job Address �(( f <br /> r <br /> # - AlidS's Phone ; <br /> 4 Owner's Name _ ... <br /> ( _ i5pr �Z�(}y phone -�r Ll t, <br /> � <br /> a�Cttw Address3 T License No. <br /> - Contrac,�dr'�`1i_' _. <br /> WELL REPLACEMENT-❑. <br /> TYPE OF WELL/PUMP: n NEW WELL-0 - DESTRUCTION ❑ a. <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ t <br /> SEWER LINES ��� Q1SP05AL FLD. POOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSISUMP5 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 'P <br /> ' ❑ Open Bottom Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C] Industrial Specifications <br /> Domestic/Private ❑ GravelPack' Cl Type of Casing Tracy Public Depth of Grout Seal Type of Grou <br /> ft <br /> Il '1 tl ❑ Other Cl Delta _ �t <br /> I i I Irrigation , -�._Approx. th I I Eastern riace Seal Installed by e 1 tV <br /> Repair WorkXDone ❑ Type of Pump <br /> H P State Work Don rV <br /> 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> i Depth t Filler Material (Below 50'1 <br /> c system par <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I.� REPAIR/AQDITION l.! QESTRUCTION I I avlailable1w thin 200 feeti1)ed if public sewer is <br /> Installation will serve:' Residence— Commercial— Other —_� <br /> Numbe hof living units: Number of bedrooms Water table depth <br /> Character-of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK, y ❑ Type/Mfg Method of Disposal <br /> PKG, TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P Y <br /> Total length/size <br /> LEACHING LINE i ❑ . Na. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p V <br /> r WSize Number <br /> SEEPAGE PITS l 1 Depth Property Line <br /> SUMPS Lf Distance to nearest: - Well Foundation P Y <br /> DISPOSAL PONDS ❑ <br /> ! 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/ofrthe San 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 /> 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 foliQwing:"I certify that in'the perfor ance i he work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." <br /> The applie t must call fo a11FrQge%rced in c ons. plate drawing averse side. ' 2., 2 e �/ <br /> v/�lr _ Date: J <br /> ��- Tit <br /> it /�/ <br /> Signed <br /> I ► FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> t ; Final Inspection by Date <br /> Pit or Grout Inspection by Date <br /> - J "= mac- �•0� � <br /> Additional-Comments: <br /> ElStk 466-6781 r 1071Lodi -3621 Manteca 7104 Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CEIVED BY DATE PERMIT NO. <br /> nZtJa;J!FR:EEH 13-24(REV.EH - <br />