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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209}466-6781 <br /> ^PERMIT EXPIRES 'f YEAR FROM DATE ISSUED 'r <br /> E {Complete in Triplicate) <br /> Ith District for a <br /> .This appcation is <br /> li <br /> Application is herebyma Sano Joaquin County Ordinance No.549 for sewage or permit construct and/or <br /> the Sn Joaquin NO. 1862 forwell/pump and the Rul s and Regulations of the San Joaquin <br /> made in compliance Nith <br /> Local Health District. , " <br /> City ' Lot Size PM <br /> Job Address ' <br /> ", <br /> Address — <br /> Phone <br /> Owner's Name ' <br /> * A f License No.!�Phone : 968 <br /> Contractor � Address � 6L" �.. <br /> TYPE OF WELLIPUMP: <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 5 !ay�L <br /> PUMP MSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ j t <br /> DISTANCE.TO NEAREST: SEPTIC TANfC <br /> SEWER LINES <br /> DISPOSAL FLD. PROP.LINE <br /> FOUNDATION AGRICULTURE WELL 0314 WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE EA CONSTRUC SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca ell Excavation <br /> ❑ Industrial Specifications <br />,F ❑ Domestic/Private. <br /> El Gravel Pack ❑ Tracy yPe o Type of Grout $. L\ <br /> F1 1 Other n Delt Depth of Grout Sem s <br /> M Public w } <br /> i 4 Irrigation {� --Approx. Depth astern - Surface Seal.Installe I by <br /> H.P. State Wor e— <br /> Repair Work Done E3.i Type of PumpV <br /> D Well D" ter <br /> Sealing Material (top 50'1 <br /> Well Destruction <br /> E - ( Filter Material (Below 501 ` <br /> I TYPE OF SEPTIC WORK:,JNEW INS ALLATION t l REPAIRlADDITION l I DESTRUCTION availableseptic <br /> wthin 200 feet.)' <br /> �f public sewer is <br /> Installation will serve: Resideric� Commercial_ Other <br /> 'o �� 3 u ber of bedrooms �[� r <br /> Number of living units: �. � l Jc J-}( rT� 1 Water table depth <br /> I , 1r�1 ����;�� � <br /> Character of soihto a de�th of 3 to ;:__ No. Compartments j <br /> ! 7 jy� } CapactY f <br /> SEPTIC TANK i�1�: t—, pe/lulfg Method of Disposal .f4 <br /> PKG. TREATMENT PLT.' ?,JL4 <br /> oun�an rope,Y ine <br /> u r, _Distance to nearest:`��ClVetl <br /> Total length/size A." i <br /> i LEACHING LINE D No. & } hgth of tines Property Line <br /> FILTER BED D Dist ance�to nearest: Well Foundation P �lY <br /> i '' Size Number C� <br /> SEEPAGE PITS I I Depth 'I Property Line I <br /> SUMPS <br /> Ll Distancelto nearest: <br /> Well Foundation <br /> I DISPOSAL PONDS Q <br /> ii <br /> I hereby certify that I have prepared thisja6plication and that the work will be done in accordance with San Joaquin county artlinanc'es, state laws, an <br /> rules and regulations of the San Joaquin 1�acal Health DIrict. <br /> g; ., <br /> r Home owner or licensed agent's sign8t I re certifies the foliowin I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> s. employ any parson in such manner as�t�tiecome subject to workman's compensation laws of California."Contractor s hiring or sub contracting signature <br /> certifies the following: "I certify that int`the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> lion laws of California." # . <br /> j The applica must call f9AaII re uire linspQctions. Complete drawing on reverse side. <br /> Signed X ' I <br /> Title: r"' — Date: <br /> FOR DEPAR'T'MENT USE ONLY <br /> Date Area <br /> 1 <br /> i Application Accepted by <br /> Date Final lnspection by Date U <br /> Pit or Grout inspection by � <br /> . i <br /> t <br /> Additional Comments: <br /> D 5tk 466-6781 D 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 /> FEECK RECEIVED BY EDATE f ERMIT"NO. <br /> INFO AMDUNT DUE AMOUNT REMITTED CA - <br /> 5 <br /> ♦,.EH 13-24 IREV. 5Y � d,9 <br /> EH 14-28 <br />