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–- ZveO <br /> APPLICATION FOR PERMIT <br /> `L(gCAL HEALTH DISTRICT <br /> SAN JOAOUiN <br /> { 1601 E. HAZEL-ION. AVE., STOCKTON, CA <br /> Telephon12091 466=6781 �,. ' <br /> PERMIT EXPIRES 1'YEARiFROM DATE ISSUED''' <br /> {Complete in Tripllcatel } l t dt t;_ • ' r' " ' application is <br /> and the Ryles and Regulatrons of the SanrJoaquin <br /> s <br /> A lication is hereby made to the Sari Joaqui D�dinalnce No.649 for sewage or permit <br /> 1862 for wel�IdpWm stall the work herein descnb <br /> PP r <br /> made in compliance wrth San Joaquin County ,p � iLc `}max i e� O> �ku ., <br /> Local"Health District. .� I' ;,... `PM <br /> L `'1 City Lot Size <br /> v""— '" <br /> � X23 ®0 '��-✓ L _ - � <br /> Job Address - Phone <br /> dress <br /> Owner's Name IT Phonal <br /> ' � License No. <br /> I r Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT Q R <br /> NEW WELL ❑ OTHER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. PROP-,LINE <br /> SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK �— A'GRICUI.TURE WELL OTHER WELL <br /> i FOUNDATION �- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA\ CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing <br /> Dia. of Well Excavation <br /> �• <br /> L1 Industrial <br /> El Open Bottom . ❑ Manteca Specifications <br /> ❑ Tracy Type of Casing <br /> ❑ m <br /> eooestic/Private C1 Gravel Pack Type of Grout <br /> ❑ Other = ❑ Delta Depth of Grou�i Seal <br /> ❑ Public lied by <br /> Surface Seal I n sta <br /> ❑ irrg <br /> Irrigation �pprox. Dept <br /> L1 Eastern / Y State Work Done <br /> Re <br /> I H.P. <br /> Repair Work Done ❑ Type of Pump 1 <br /> i " Sealing Material Stop 50'1 <br /> k Well Destruction ❑ Well Dia eter --� Filler Material (Below 50') <br /> Depth <br /> available within 200 feet.)______, <br /> TYPE OF SEPTIC WORK: NEW 1NSTALLATIQN'Q •REPAIRlADD1T,ION Di DESTRUCTION ❑ 1N septic system permitted if public sewer is <br /> 'Installation will serve: Residence Commercial_ Other <br /> Number of living units: 'Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: f No.'Compartments <br /> ❑ Type ` Capacity <br /> SEPTIC TANK '"Method of Dispose! <br /> PKG. TREATMENT PLT. ❑ 1 Foundation r Property Line <br /> Distance to nearestt_ �Wel1 i <br /> ./ .a- . - r��`"-' Total length/size' <br /> LEACHING LINE ❑ No. & Length of-lines.-/ <br /> Property.tine y <br /> `FILTER BED ❑ Distance to nearest: Well Foundations <br /> t i, <br /> SEEPAGE PITS ❑ Depth <br /> Size. Number <br /> ` <br /> SUMPS ❑ Distance to nearest: Well Foundation 1 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I"have prepare this application and that the work will be done in, <br /> accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. i <br /> Home owner or licensed agent's;signature certifies the following: "I certify that in the,perforrriance of the work for which this permit is issued, I shall not <br /> signature <br /> employ any person in Such rt fy that n the perfo mance of he work for which tht to workman's is perm the issued,tionf1 shall employapersonslsubject t woring or rkman is eompensa <br /> certifies the following: <br /> k tion laws of California:" _ <br /> lThe applicant st call for ail–re'-iired-inspec'ns. trete drawing on reverse side. -a �� <br /> Date: <br /> Signed <br /> FOR D ARTMENT USE <br /> ONLY ;Z <br /> E Area <br /> Date; Z <br /> Application Accepted by.' <br /> Pit or Grout Inspection by <br /> r Date Final Inspection by" -�— Date <br /> . t <br /> Additional Comments: ' <br /> ["IStk 466-6781 1] Lodi l}369-3621 Q Manteca 823-7104 Ll Tracy 835-6385 <br /> 'Applicant- Return ail copies to;'Environmental Health Permit/ <br /> Servic 601 E. Hazelton Ave., P 0. Box 2009,tiStk., CA 95201 <br /> CK# RECElVED9Y DATE PERMIT`NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED, i CASH <br /> INFO <br /> + EH13-24(REV.Va5) <br /> EH 14-28 <br />