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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicates <br /> t and/or.install the work <br /> . This <br /> cation is <br /> Application is hereby madeSanoJoa um County Ordinance uin lNa 549 for sewage orealth District for a 't to No. 1862 for cwell pump and the Rules and IR Regulations of the San l Joaquin <br /> made in compliance with q <br /> Local Health District. / �D—� <br /> 7 /�} ,� r 1AIMM"5 City r " Lot Size PM <br /> Job Address <br /> 04 V Address ' Phone <br /> Owner's Name + <br /> Contractor Address <br /> License No. Phone <br /> TYPE OF WELL/PU f?: J NEW WELL ❑ k WELL REPLACEMENT ❑ DESTRUCTION ❑ E <br /> PUMP INSTALLATION- <br /> SYSTEM REPAIR ❑ OTHER ❑ I <br /> SEWER LINES DISPOSAL FLIT. PROP. LINE- <br /> DISTANCE <br /> INE DISTANCE TO NEAREST: SEPTIC TANK , <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIONS • Dia. of Well Casing <br /> 13 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation . , f N <br /> ` Type of Casing Specifications <br /> El Domestic/Private y 0 Gravel Park- ❑ Tracy Type.of-Grout t - <br /> F] Public + ❑ Other n Delta Depth of Grout Seal I - <br /> ! I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> 4State Work Done <br /> Repair Work Done L3Type of,Pump H.P. 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> t Depth <br /> Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALCATION ° REPAIR/ADDITION ! I DESTRUCTION I I (Noavas septic <br /> system <br /> hin m rented -+f public sewer is <br /> ` installation will serve' eetA <br /> Residence :�Commereial"_-._�Ather' <br /> `� <br /> Number of living units: Number o bedroo�� <br /> Water table depth <br /> Character of soil to a depth of'3 feet: ��^^77��� > <br /> T e/Mfg Capacity No. Compartments <br /> SEPTIC TANK «ti W Ji Yp E <br /> Method of Disposal <br /> PKG. TREATMENT PLT'. ❑ u <br /> t Distance to nearest: `t Well Foundation Property Line <br /> .I <br /> LEACHING LINE I No. fi, Len'h f lures _. 7a�tal length/size <br /> Z� <br /> -.: <br /> FILTER BED t _t ❑ Distance to nearest: <br /> Foundation Property Line <br /> SEEPAGE PITS I I i Depth ize <br /> { <br /> SUMPS <br /> �. Distance to nearest: Well Foundation Property Line <br /> f a ° <br /> DISPOSAL PONDS ❑ ` <br /> I hereby certify that I'have prepared this application and that the work will be done in accordance with San Joaquin county ordinance k, state laws, a'n`d <br /> r rules and regulations of the San.Joaquin Local Health District. <br /> Home owner or of the S's signature certifies,ihe following: "I certify that in the performance of the work for which this permit is Fssueij shall not <br /> employ any person-in-such rinanner as to become subiect to wt) compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: ':i certify that in the performance of the.work far which this permit is issued, I shall employ persons subject to workman's compensa <br /> tion laws of Caliiornia." <br /> The applicant must call for -re inspections,Complete drawing-06 rreverse <br /> ` ,,••-�' <br /> Signed X�� 1 Title: r Date: , <br /> it .E DEPARTMENT USE ONLY <br /> Date 0 !J Area <br /> Application Accepted by <br /> Final Inspection by Date <br /> Da e <br /> Pit or Grout Inspection-by ! , <br /> Additional CommenF <br /> EJStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835,686 <br /> Applicant Return all copies to: Environmental Health Permit/.Services 1601 E, Hazelton Ave., P.O. Box 2009 Stk., CA 85201 <br /> I FEE CK RECEIVED BY ' DATE PERMIT NO. <br /> INFO AMDUNT <br /> DU <br /> AMOUNT REMITTEDL" CASH <br /> + EH 13-24 IREV.t • �� f ~ � <br /> EH 14-28 ' ,�_ <br />