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APPLICATION FOR PERMIT Lf <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <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) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 11362 for welllpump and the Rules and Regulations of the San Joaquin <br /> Local.Health District. Z Sa P_ /4 o.G co-}—+ <br /> Z. ity <br /> Lot Size PM <br /> Aob Address Phone .20 Addres� <br /> �wner's Name <br /> ''`r,,, Address <br /> In License No. Phone_ <br /> 7-contractor.___sr — DESTRUCTION 1-1TYPE OF WELL/PUMP: NEW WELL F] WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR El OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. POOP, LINE <br /> DISTANCE TO NEAR TIC TANK — PITS/SUMPS - <br /> FOUND ATI AGRICULTURE WELL OTHER WELL <br /> IONS <br /> CONSTRUC <br /> INTENDED USE TYPE OF WELL PROBLEM Dia, of Well Casing <br /> ( <br /> ❑ Mantec ia. o cavation❑ Industrial ❑ Open Bottom Specifications � <br /> Trac Type of Casing <br /> O domestic/Private �.. ❑,Gravel Pack y peptic of Grout Seal- 'Type of Grout -- <br /> I (-I Public t 1 _ - n Delta <br /> Ax. Depth I 1.Eastern SLjHke Seal Installed by <br /> 1 I I irrigation — ppro _ State Work Done F ) <br /> t H.P. <br /> Repair Work Done, ❑ Type of Pump 3 <br /> Sealing Material (top 501 <br /> + Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> l Depth <br /> TYPE OF SE?TIG WORK: NEW INSTALLATION I I REPAIR/'ADDITION E I DESTRUCTION I (Nailablerwi hin 200 feetc system .) i! public sewer is <br /> installation wilt serve: Residence_ Commercial Other f f <br /> Number of living units: Number of bedrooms . Water table depth t/ 1 <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments 1 <br /> SEPTIC TANK ❑ Type/Mfg l.�- "Method of Disposal f <br /> PKG. TREATMENT PLT. ❑ a <br /> Distance to nearest: Well Foundation Property Line V' <br /> 4 <br /> ! Q <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property tine f <br /> FILTER BED I ❑ Distance to nearest: Well Foundation [ <br /> I Number i <br /> I SEEPAGE PITS ! l 1 Depth n, <br /> Size 1 t <br /> Ll Distance to nearest: _ Well Foundation Property Line <br /> SUMPS � ' a ^ <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, and <br /> ' rules and regulations of the San Joaquin Local Health District. _ <br /> Home owner or licensed agent's signature certifies the following: "I certify that in' performance of the work for which this permit is issued, V signature <br /> shall not }rC� <br /> employ any person in such manner as to become subject to <br /> workman's <br /> which.this at pon laws issued,s of lfl shall employ peContractrsonsrsubject to workman's ring or tgcompensa- }t <br /> certifies the following: "I certify that in the pes <br /> I tion laws of California." <br /> The app ant c r all re fired inspections. Complete drawing on reverse side. <br /> t✓1-�Jc` Date: <br /> 1 ' Title: i <br /> Signed } _' <br /> FOR DEPARTMENT USE ONLY b <br /> Date v Area ` <br /> l Application Accepted by <br /> 2_. D <br /> Date Final Inspecti n by Date <br /> k Pit or Grout Inspection by �`�atJ <br /> l Additional Comments' <br /> 1 ElStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 5 C X. � CWNA0 <br /> Applicant- Return all copies to: Environmental Health Permit/ServicesN1601 E, Hazelton Ave... P.O. [Box 20/09, Stk., CA 95201 CAX. , <br /> (1)lJL ,/T <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE [yPERMIT'NO..n <br /> INFO <br /> +.EH13-241REV.t/n5i 3�•VV ��' <br /> EH 14-26 <br />