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APPLICATION FOR PERMIT <br /> ,i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ,i PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) _ <br /> .This <br /> ll <br /> work here' <br /> Application is herebyyNma, <br /> h Sanothl Joaquin County Ordinance No.District549 for sewage or'No�1862 forcweN apumrQnand the Rules and n is <br /> 1Regu�lationnss of the San Joaquin <br /> u n <br /> Loc a in compliance ��A <br /> Local Health District. �� �. <br /> City <br /> Lot Size PM <br /> ' � .. <br /> Job Address WNr, <br /> - Phone ` <br /> � � Address <br /> Owner's Name M d� <br /> - .- License No. Phone <br /> Contractor Address <br /> WELL RE CEMENT ❑ DESTRUCTION ❑�,, <br /> TYPE OF WELL/PUMP: I� NEW WELL ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> [I Domestic/Private 1-1GravelPack ❑ Tracy Type of Casing <br />' El Public ❑ Other <br /> 1-I Delta Depth of Grout Seal Type of Grout v <br /> ❑ Irrigation _ Approx. Depth ❑ Eastern Surface Seal Installed by <br /> of Pum H.P.. State Work Done O <br /> Repair Work Done -1 pe <br /> p f ` <br /> Well Destruction ❑ WeA Diameter Sealing Material )top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE—CF—SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRUCTION (Nailabltiwi h system perr <br /> feetitted 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 /> Character of soil to a depth of 3 feet: No. Compartments \-` <br /> ❑ p Type/ Capacity <br /> SEPTIC TANK :I YP g t Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Pro a Line <br /> II Distance to nearest: Well Foundation P rtY j. <br /> ' Total length/size <br /> LEACHING LINE ❑ No. & Length of lines ----------- pr6perty Line <br /> FILTER BED <br /> 0.11 Distance to nearest: Well Foundation <br /> v <br /> i <br /> I Size Number ii <br /> SEEPAGE PITS ❑it Depth Pr�perty Line <br /> SUMPS ❑Ir Distance to nearest: Well Foundation <br /> I r <br /> DISPOSAL PONDS ❑ <br /> I 1 hereby certify that I have prepared this application and that the work will be done inaccordancewith 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: "I certify that in the performance of th work for which this perm-is issued, !she not <br /> F employ any person iCalifornia. Contractor's <br /> n such manner as to become subject to workman's compensation laws of ornia. ' rs hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall mploy persons subject to workman's ccmpensa- <br /> tion laws of California." <br /> The applic ust call f r all re uired in ctions. Complete drawing on reverse side. <br /> i <br /> Date: <br /> Title: <br /> k Signed <br /> i FOR DEPARTMENT USE ONLY / <br /> Area <br /> Application Accepted by <br /> Date <br /> Final Inspection by <br /> Pit or Grout Inspection by Date <br /> I Additional Comments: .i !. s <br /> El Stk 466-6781 ❑tiLodi 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 /> ( RECEIVED BY DATE PERMIT NO. <br /> 1 <br /> INFOFEE <br /> AMOUNT DUE AMOUNT REMITTED G SH <br /> 5- <br /> + EH 13-24IREV. <br /> EH 14.28 <br />