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APPLICATION FOR PERMIT A O�:�ts <br /> ~ SAN JOAQUIN LOCAL HEALTH DISTRICT �U <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) application is <br /> APP' <br /> un Ordinance.No.549 for sewage or No. 1662 for welllpump and the Rules and Regulations of the San Joaquin h <br /> Application is hereby made to the SanCJooaquin Local Health District for a permit to construct and/or install the work herein described. s <br /> made in compliance with San Joaquin county F 1. <br /> Local Health District. PM <br /> Lot Size I <br /> City <br /> Job Address 2 9 2 K n <br /> Phone – <br /> Name l—e a t h a Williams' Address <br /> Owner's <br /> I <br /> E t License W2-892--3 Phon <br /> 1 1 P r�ddres's DESTRUCTION Q ,� 1 <br />"E Contractor WELL REPLACEMENT ❑ l�J <br /> NEW WELL Q OTHER ❑ <br /> TYPE OF WELL/PUMP' SYSTEM REPAIR Q ' <br /> PUMP INSTALLATION ❑ DISPOSAL FLD. PROP. LINE <br /> SEWER LINES OTHER WELL PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL <br /> FOUNDATION Ll <br /> ONSTRUCTION SPECIFICATIONS <br /> WELL PROBLEM CDia. of Well Casing <br /> INTENDED USE TYPE OF <br /> Q ❑ Open Bottom L) Manteca' , Dia. of Well Excavation Specifications <br /> ❑ Industrial TType of Casing <br /> ❑ racy <br /> ❑ Domestic/Private ❑ Gravel Pack Type of Grout <br /> ❑ Delta Depth of Grout Seat 8 <br /> ❑ Public ❑ Other 'r % Surface Seal Installed by <br /> ❑ Irrigation �J�pprox. Depth L3Eastern State Work Done <br /> Type f Pump ��� N.P. <br /> o <br /> Repair Work Done ❑ Sealing Material Stop 501 <br /> Well Destruction * ❑ Well Diameter Filler Material (Below 50') <br /> s' Depth <br /> vailable within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer es <br /> Installation will serve: Residence <br /> Commercial— Other�— <br /> lNumber of bedrooms Water table depth <br /> 1l Number of living units: { � <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of-Disposal <br /> A .. <br /> { <br /> PK G. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well $ <br /> { Total lengthtsize <br /> f LEACHING LINE ❑ No. &*Length of lines Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: Wei{ <br /> � Size Number ' <br /> t SEEPAGE PITS ❑ Depth pro Line <br /> r SUMPS <br /> ❑, Distance to nearest: Well Foundation pew' <br /> DISPOSAL PONDSstate laws, and <br /> I hereby certify that l have prepare❑ <br /> t application and that the work will be done in accordance with San Joaquin county ordinances, <br /> E d this <br /> f rules and regulations of the San Joaquin Local Health District. <br /> g work for <br /> Home owner or licensed agent ne 9as torbecome s the f o to wng'. "I 'srtcompensation Iw saof Califo�niahe Contract r's1hiringr orr s b1 cont actingrmit is issued, lsignat shall ore <br /> employ any person in such man arsons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p <br /> r tion laws of California." <br /> The applicant must call for { q fired inspections. Complete drawing on reverse side. - <br /> i Date: <br /> Title: I <br /> Signed r i <br /> f FOR'DEPARTMENT USE ONLY <br /> Date <br /> S 1 �� Area <br /> Application Accepted by pate <br /> iDate�1 Final inspection by <br /> � Pit or Grout inspection b <br /> .,..ice <br /> Additional Comments: 71Q4 EI Tracy 2009, Stk., CA 9 <br /> L3 Stk 466-6781 i Lodi 369-3621 ❑ Manteca <br /> Applicant Return all copies to: Environmental Health Permitiservices 1601 E. Hazelton Ave., P.O. Bax <br /> r RECEIVED BY DATE PERMIT NO. ,* <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> } INFO i�15 r• �� i]y <br /> � EH13-24(REV.t/Rsl �Ua T <br />