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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T OIC AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) <br /> ribe <br /> . This <br /> cation is <br /> t and/or <br /> all the work <br /> n desc <br /> Application is hereby made to Joaquin County ordinajoaquin nHealth District for a ce No.549 for sewage or permit <br /> No. 1862 forGwell//pump and the Rules and(Regulations of the San Joaquin <br /> made in compliance with San4 <br /> Local Health District. { <br /> k� � �, � Lot Size PM t <br /> Job Address <br /> —9—W,� �' ��L�' Gity/1^ <br /> r ,(�fQi Phone U<=J <br /> .� Address I <br /> Owner's Nam <br /> i v_ _4°- ' License No. Phone <br /> Addres <br /> Contractor, _ � ��"'r-_-�- <br /> NEW WELL ❑ WELL REPLACEMENT 0- DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER <br /> 'PUMP INSTALLATION <br /> SEWER LINES -_—..�---- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> PROBLEM CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLLDia. of Well Casing <br /> ❑ Open Bottom E3 Manteca Dia. of Well Excavation <br /> E3Industrial Specifications <br /> Type of Casing (� <br /> ILDomestic/Private ❑ Gravel Pak LJ Tracy Depth of Grout Seal Type of Grout <br /> FI Public 171r C <br /> Other Delta t <br /> I I Irrigation -ApproxDepth l I Eastern Surface Seal installed by h <br /> 1,41 u State Work Done ` <br /> Repair Work Done P Type of Pump a H.P. C <br /> O <br /> Sealing Material Itop 50'1 <br /> Well Destruction ❑ Well Diameter 50'I <br />` Material I Below <br />! Depth I Filler Mate {� <br />' TYPE OF SEPTIC WORK: NEW INSTALLATION i.I REP LI DESTRUCTION l 1 arvailablelc system wthin 200 feet.) it public sewer is <br /> Installation will serve: Residence, Commercial— Other <br /> Number of living units: Number of bedrooms <br /> i Water table depth <br /> Character of soil to a depth of 3 feet:i No. Compartments <br /> g Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> C Type/MfCapacity <br /> SEPTIC TANK 1 Property Line <br /> Distance;to nearest: Well Foundation <br /> 't Total length/size <br /> LEACHING LINE L1 No. & Length of lines p y Pro art Line R i <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> _# <br /> Size dumber- <br /> SEEPAGE PITS l 1 Depth ' Property Line <br /> SUMPS Cl Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ ` <br /> will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work <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." Contractor's hiring or sub-contracting signature <br /> nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the following:"I certify that in the performa <br /> tion laws of California." A <br /> I!— <br /> The applicant must call for required inspections. Complete drawing on reverse si 9. <br /> r r Title: — <br /> Date: <br /> Signed X �*..- <br /> r FO DEPARTMENT USE ONLY <br /> R % <br /> Date Area <br /> Application Accepted by <br /> ' Final Inspection by Date <br /> Pit or Grout Inspection by Date - _ <br /> l <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .i <br /> fFEE AMOUNT DUE AMOUNT REMITTED -C H RECEIVED 9Y DATE PERMIT NO. <br /> )NFO <br /> +.EH 1320(REV•t/H 5Y <br /> 3 35 <br /> EH 14-29 <br />