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APPLICATION FOR PERMIT <br /> SAN JOAQUIN FOCAL HEALTH DISTRICT S i_P 5 1984 <br /> 1601 E. HAZEL—I ON AVE., STOCKTON CA <br /> Telephone (209) 466-6781 SAN JOAQUIN LOCAL <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT, <br /> f (Complete in Triplicate) (2/K 9/— / 75� <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 /> l made a compliance with,San Joaquin County.Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. �, 11 ,I <br /> j�/ Lot Size PM <br /> Job ddress City <br /> �DOwner's Name Address �* Phone <br /> ew <br /> Contractor's Name <br /> License No. Phone `y <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1-1DESTRUCTION11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t �` SEWER LINES DISPOSAL FLD.l I PROP. LINE u Y <br /> DISTANCE TO NEAREST: SEPTIC TANK _��_ <br /> i3 . - FOUNDATION AGRICULTURE WELL""' OTHER WELL �°`PITS75UMPS �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Jt <br /> ❑ Open Bottom, t ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1Un'1S <br /> ❑ Industrial ,�,/ , <br /> L]r Gravel Pack racy Type of Casing Specifications r V" <br /> ' [�1orrlestic/Private Type of Grout <br /> r <br /> 11 Public ❑ Other ❑ Delta Depth of Grout Seal yp \ <br /> ---Approx. Depth El Eastern Surface Seal Installed by <br /> ❑ Irrigation app l <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. 11� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material (Below 501 <br /> (Noper <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION ❑ availablerw th ne200 feetitled if public sewer is <br /> d <br /> i <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth ' 15 <br /> SEPTIC TANK El. Type/Mfg Gapacity No. Compartments <br /> El of Disposal <br /> PKG. TREATMENT PLT. <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> _ rr <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> F FILTER-BED ❑ Distance to nearest: Well Foundation Property Line <br /> l SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well y Foundation Property Line - <br /> " DISPOSAL PONDS T <br /> 1 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 /> 4 <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 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." Contractors hiring or subcontracting signature <br /> which this permit is issued,I shall employ persons subject to workman's compensa- <br /> cert'rfies the following:"I certify that in the performance Of the work for <br /> tion laws of California." <br /> The applicant m st call for all required,,kpipections. Co plate drawing on reverse sicl . `o O <br /> Signed Title: /J�, Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area G <br /> L Pit or Grout Inspection by <br /> pate — J Vr -Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE jHRMIT�JNO.7+ EH 13-24(REV.101831 �� �j� i�-�'sl3 C. �� �� L3 <br /> EH W28 <br />