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I: <br /> - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E HAZEL-TON-AVE-,, STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> is <br /> madlg in conmplieieby ance with Sanade o the Joaqu nnCounty Ordinance Nuin Local th District for a o.549 for sewage or permit <br /> No. 1862 forcwellipump and the Runes and IR Regulations of tlhe Sanapplication <br /> Joaquin <br /> Local Health District. <br /> /D 77. <br /> Ci t Size PM <br /> Job Address ! q(� <br /> l� Address Phone <br /> Owner's Name <br /> Qba <br /> Contractor <br /> `*� Address v ?=License Na.-� _L�.L PhoneAW r <br /> TYPE OF WELLIPUMP,j% �EWELL ❑ WELL REPLACEMENT LJ-'J, <br /> DESTRUCTION ❑ ;I <br /> # PUMP INSTALLATION *-'J., .4 SYSTEM REPAIR ❑ OTHER a O <br /> tDISTANCE TO—NEAREST--"SEPTIC TANK--- -- SEWER-LINES _ - - DISPOSAL-FLD.-----.- PROP-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �A INTENDED USE TYPE OF WI=LL PROBLEM AREA CONStRUCTION SPECIFICATIONS <br /> i❑ Industrial © Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 14e0omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> J Cl Delta Depth of Grout Seal Type of Groot- <br /> 11. - <br /> � , "TIM Public ,�,. .Ll Other - <br /> it I Irrigation 't }r :.Approx. Depth I I Eastern Surface Seal Installed by <br /> ilRepair Work Done b�tType of-,Pump _�r,_ _� H.P. <br /> State Work Dane <br /> t Well Destruction ❑ Weil Diameter Sealing Matefial Itop501 l <br /> Depth Filler Material IBelow�50'I <br /> TYPE OF SEPTIC WORK: NEW INSTAVLrA-TION 11 REPAIRJADDITIONIl1 ,DESTRUCTION I I INo septic system permitted if public sewer is <br /> I ! <br /> L, available within 200 feet.) s <br /> I Installation will serve: Residence i" `Commercial_ Other_ <br /> Number of living units: Number ofJ'tiedrooms. '�r', <br /> Character of soil to a depth of 3 feet: . <br /> '—34" �� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capac ty fF No. Compartments <br /> PKG. TREATMENT PLT. <br /> Method of Disposal <br /> Elt <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size`"' -_ <br /> r FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS ❑ Distancetonearest: Well Foundation Property Line <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 ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or lic agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any p on in suc manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies te;E <br /> that in the perform of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion YawsThe applieq re n o amp to drawing on r se sid . <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> r <br /> El 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 /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> + EH 13.24(REV.,/115) �-J _ <br /> F EH 14-211 <br />