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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZELTON AVE:;STOCKTON, CA <br /> '-- Teleption''c Oso 466-67,81 <br /> SUED <br /> PERMIT EXPIRES 1 YEAR FROM DATE IS <br /> I� <br /> (Complete in Triplicate) <br /> all the work herein <br /> cation is <br /> Application <br /> i Ihereb with a to the San <br /> nnJoaqui County Ordinance No.District549 for sewage o permit <br /> ND 1862 for wellldpump atnd the Rules and R gulat Dons of he Son 1 Joaquin <br /> made In p i <br /> a <br /> .=Local Health District.=��` �� T � ". ' .,- <br /> FT", <br /> ar ��� }� �V r, PM � <br /> 93� x 4 City Size <br /> Job Address . x wt <br /> Phone <br /> Address <br /> Owner's Name a) <br /> Contractor Address�� <br /> /9�7;License No. Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SYSTEM REPAIR C1OTHER ❑ , <br /> 0 PUMP INSTALLATION 1:1 :. <br /> DISTANCE TO NEAREST: SEPTIC.TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS = <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial 3 ❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack... - ❑ Tracy F T e'of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal l I y. <br /> rox. Depth ❑ Eastern - Surface Seat Installed by <br /> ❑ Irrigation app ;;j —A <br /> State Work Done <br /> Repair Work Done ❑ ype of Pump _-�<L—y H.P. <br /> i Well Destruction Iall Diameter ...Sealing Material Itop 501 , <br /> pth 1— Filler Material (Below 501 <br /> (No se <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION availabpelwi hine200 feet1tted if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> 3 <br /> Number of living units: Number of bedrooms Water table depth' <br /> Character of soil to a depth of 3 feet: fl 3 <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ <br /> y <br /> Distance to.nearest: Well Foundation, Property Line <br /> I w Total length size <br /> LEACHING-LINE ❑ " No.-& Length of lines - Property Line <br /> FILTER BED ❑ Distance to nearest:Well :L Foundation t <br /> " SEE7?'AGE PITS LlDepth <br /> Size Number ` <br /> SUMPS ❑- Distance to nearest: Well Foundation Property Line f <br /> : .. <br /> DISPOSAL PONDS ❑ <br /> –Thereby certify th ave prepared this application and that the work will be done in accordance with San Joaquin county ordiriances, state laws, and <br /> •-"'"r`ules_and reg ions of a an Joaquin Local Health District. <br /> Home own or licensed a ant's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shah not <br /> employ a person in such anner as to become j t to workman's compensation laws of California." Contractor's hiring or°sub contracting signature <br /> certifies a foli0"" <br /> ig: "1 fy that in rf __ a of the work for which this permit is issued,I shall employ persons subj t to workman's compensa <br /> 4 tion fa of Calif rnia." <br /> The plic nt for all ons. Co plate drawing on rave ide. <br /> o- Title: <br /> Sign �= Date: w 4 !O3 <br /> " <br /> FOR DEPARTMENT USE ONLY <br /> Dat ` V Area o63 <br /> I Application Accepted by <br /> Date <br /> Date Final Inspection by p t. <br /> Pit or Grout Inspection by a <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi,•'36J�3fi21 `mow O'.fVlanteca "923-719. C3 Tracy 835-6385 <br /> Applicant- Return all cdpies to•'Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk CA 95201 a <br /> _FEE ' ' AMOUNT"REMITTED ; CK RECEIVED BY`.,. DATE. PERMIT NO. i <br /> INFO AMOUNT,DUE' CASH'q <br /> +EH 1324 il <br /> (REV.t <br /> EH 1428 <br />