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APPLICATION FOR PERMIT w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL FON AVE., STOCKTON, GA <br /> ' Telephone (209) 466 6781 <br /> �! ,PERMIT EXPIRES S YEAR FROM DATE ISSUED <br /> I <br /> (Complete in Triplicate) <br /> rk <br /> , This <br /> cation is <br /> Application is hereby made to the San Joaquin Local Health Districtfor sewage or permit <br /> 1662 for well/pumor 1p and the Ruall the in s and IR Regulations of the San�Joaquin <br /> made in compliance with San Joaquin County Ordinance No.54 9 444 <br /> Local Health District. <br /> i. �• 3. i <br /> City�i�.� Lot Size PM <br /> .3 <br /> r7-y- <br /> Address <br /> U hone <br /> :� <br /> ner's Name. <br /> Address <br /> ntractor Address - <br /> L:icense•No.--�---? Phone <br /> NEW:WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PE OF WELLlPUMP:. OTHER ❑ I <br /> PUMP INSTALLA�'ON ❑ SYSTEM REPAIR ❑ yy <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL•IFLD. F PROP. LINE <br /> � CULTURE OTHER WELL PITSlSUMPS <br /> FOUNDATIONAGRI <br /> - VVV <br /> INTENDED USE TYPE OF L PflPBL•EM AR fGONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑.Industrial '; 1711 Open Bottom Dia. of Well Excavation <br /> racy - Type of Casing t Specifications <br /> ❑ Domestic/Private 1-1 Gravel Pack out Seal Type of Grout <br /> m Public 1=1 Other n Delta>>. Dep _r <br /> } 'Ap `Depth l 1 Eastern Surface Saar 1n d by <br /> I I Irrigation { — � <br /> tate Work Done <br /> F _ <br /> Repair Work Done ❑ T of Pump <br /> Well Destruction 0 Well Diameter Seaking Material (top 50'1 <br /> '. <br /> Depth 1 Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIRlADDITION l 1 DESTRUCTIO (Nailableseptic <br /> within 200 feet.) if public sewer is <br /> Installation <br /> will serve: Residence! Commercial_ Other <br /> Number of living uni1ts: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No..Compartments <br /> +_. Capacity <br /> SEPTIC TANK ""0`TYPelMfg t r <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> ' Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation P Y <br /> Number <br /> SEEPAGE PITS l 1 Depth Size a <br /> o Foundation Property Line <br /> SUMPS Cl Distance to nearest: Well k <br /> I DISPOSAL'PONDS ❑ Y <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 of the San Joaquin Local Health District. <br /> i 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 following: "I certify that in the performance of the work for which_this.permit+s,issued„I.shallemploy.persons.subject to workman's compensa- <br /> tion laws of California.” <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title:- Date: <br /> Signed X FOR DEPARTMENT USE ONLY <br /> Ij <br /> Date Area <br /> Application Accepted by <br /> DFi al Inspect on by Date <br /> Pit or Grout Inspection by r� ate r <br /> 3E _ - 1 - <br /> Additional Comments: <br /> ❑Stk'-466 67$1 " ❑ Lodi 3fi9-3621 ~ ❑ Manteca 3-7104 r❑ Tracy 835- 5 <br /> Applicant:.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20M, Stk., CA 95201 <br /> j # <br /> E RECEIVED 8Y DATE PERMIT NO. <br /> FE <br /> !� <br /> INFO <br /> EAMOUNT DUE AMOUNT REMITTED -C- I <br /> 1-41-1 2z3-C7 <br /> r EH 13-24(REV.3/H 5) �! .w <br /> rs <br /> EH 14-28- <br /> �!!� <br /> r <br />