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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> 6Telephone (209) 466-6781 <br /> ' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) {)cation is <br /> If <br /> County Ordinance Na.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> A Application is hereby made to the an Jo; Local Health District for a permit to construct and/or in the work herein described.This app <br /> made in compliance with San Joaquin <br /> Local Health District, <br /> City <br /> Lot size 00 1'�r PM <br /> Job Address 6 <br /> jj+�Address � (��. 0 Phone �— <br /> 41A +✓ <br /> Owner,s Name ^Z <br /> 1 ( License No Phone <br /> Address <br /> Contractorers— WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> NEW WELL OTHER ❑ <br /> TYPE:OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> i PUMP INSTALLATION ❑ I DISPOSAL FLD. PROP. LINE _ <br /> _ - <br /> DISTANCE TO NEAREST:.SEPTIC.TANK SEWER LINESPITSISUMPS <br /> AGRICULTURE WELL OTHER WELL <br /> FOUNDATION l— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing CP <br /> Dia. of Well Excav tion Dia. <br /> ❑ Inoustrial ❑ Open Bottom ❑ Manteca CSpecifications <br /> Gravel Pack ❑ Tracy Type of Casing 99m <br /> ZomesticlPrivate Type of Grout <br /> ❑ Other F1 Delta Depth of Grout Seal <br /> F1 Public PN J <br /> Approx. Depth l 1 Eastern Surface Seal Installed �y_ <br /> ILA <br /> I i Irrigation H P State Work Done <br /> Repair Work Done C7 Type of Pump Sealing Material (top 501 W <br /> Well Destruction ❑ Well Diameter -- Filler Material (Below 501 <br /> Depth <br /> available within 200 feet.) <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> I <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> i Character of soil to a depth'of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> it Distance to nearest: Well Foundation P Y <br /> it <br /> '. Total length/size <br /> LEACHING LINE ❑ 1 No- & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well. Foundation <br /> Size Number <br /> SEEPAGE PITS I 1 !i Depth <br /> Foundation Property Line <br /> ' SUMPS Cl^ Distance to nearest: Well <br /> _ <br /> DISPOSAL Pq In a ❑ <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 licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I she not <br /> ring or <br /> signature <br /> ws <br /> er ppioy any person in sulc emar the as to n the come subject <br /> bj performance the workman's <br /> ork which this tionperla is issued,California. <br /> a ifoshall emploty persons lsubject to workman's gompensa--- <br /> � cert 9: „ <br /> tion laws of California." <br /> The applicant must call for ell required inspections. Complete drawing on reerse side. r <br /> 11 <br /> 1>8111 Date: <br /> Title: <br /> Signed X <br /> �) FOR DEPARTMENT USE ONLY <br /> Aby!] <br /> eDateArea <br /> Application Accepted bFinal inspection byDateit or Grout InspectionDateAdditional Comments: `13 Stk 466-6781 ❑ Manteca 823-70 ❑ 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 /> CK PERMIT'NO. <br /> FEE MOUNT REMITTED RECEIVED BY DATE <br /> INFO AMOUNT DUE CASH <br /> + EH 13-24(REV.1/tti 51 <br /> p p o� � <br /> EH 14-26 it <br />