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APPLICATION,FOR PERMIT <br /> SAN JOAO,UIN.LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 .:.,.. , ,. :. IA- <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,ip <br /> (Complete in.Triplicate),a; rC ' <br /> all the work <br /> n described. This <br /> Application is hereby made to the San CJoaquin ounty O dinal He No.Districtcation is <br /> alth549 for sewage or INo. 1862 for well/pump t to construct and/or and the Rul s and IR gulati of•the San!Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District. <br /> City Lot S <br /> Ci ize PM <br /> Job Address - <br /> _ Phone <br /> Owner's Name t � A�� Sl �&� <br /> Address. <,__�— � "` License No. <br /> Contractor "Y �' ^ ' <br /> ^'WELL REPiAGEMENT ❑ "-DESTRUCTION : s <br /> TYPE OF WELL/PUMPT' s ..,. NEW WELL lL]�""� '"" OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El <br /> DISPOSAL FLD. PROP. LINE` <br /> DISTANCE TO'NEAREST: SEPTIC TANK <br /> SEWER LINES PITS/SUPS <br /> r FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> TYPE OF CNELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R... <br /> INTENDED USE - --�— Dia. of Well Casing <br /> t ❑ Open Bottom t ❑ Manteca Dia. of Well Excavation } <br /> I ❑ Industrial W Type of Casing Specifications 4 <br /> ❑ Domestic/Private ❑ Grave"Pack,- , ❑ Tracy yp Type of Grout <br /> 44- " `"'x'"""`%❑`D'elt'a `Depth-.of Grout Seal <br /> t ❑ Public '." C] Other Surface Seal Installed by <br /> F �pprox. Depth ('71 Eastern P (71 irrigation i f State Work Done <br /> H.P. 1. <br /> + Repair Work bone Ll Type of Pump ^1. t <br /> k Well Destruction " [-IWell Diameter-� Sealing Material,)top 50') i <br /> Depth t -,4 -Filler Material (Below-501. <br /> Davailable within 200 feet,.) <br /> g TYPE OF_SEPTIC WORK: NEW IN57ALLATION ❑; REPAIR/ADDITION �; ESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t r <br /> f . t <br /> lnstallation4will serve: Residence Commel Oex,= :�,r <br /> Num6ervf.living units: --t- Number of bedroomsWa rr-ta❑ile depth <br /> Character of soil to a depth of 3 feet: ti k ' <br /> L t � Capacity No. Compartments <br /> SEPTICTANK ❑ TypelMfgti�a ss* � Method of Disposal � .�` <br /> PKG4 TREATMENT PLT. ❑ 1 r Foundat on' 3 a` 1 Property Line <br /> 1°Distance to nearest:—'-Well <br /> ilp., ,, . ` <br /> �arTotallengthlsize <br /> ' LEASHING LINE 0. & Length of lines tf` r� <br /> Foundation s Property Line; 4 <br /> FILTER-BED <br /> ❑' Distance to nearest: Well <br /> 6 � Size <br /> �_F/oun�da <br /> NumberSEEPAGE PITS TiY Depth -� r Property l ine�'SUMPS .;rDistance to nearest: Well ' <br /> A <br /> DISPOSAL(PONDS- fl,. <br /> ! hereby certify'that�l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state laws, and <br /> uin_Local.Health District..,.r,... <br /> rules and regulations of the San J., . work for <br /> Home owner or�n m such manner signature tbecomes the following: <br /> workman's ttcompensation laws of California." Contractor's1hving orthis�sub-contracting signaturmit is issued, I shall re <br /> employ any pe p persons subject to workman's compensa- <br /> certifies the following: "I certify that in the pert rice of4the'work far which permit is issued,1 5hah1 employ pe 1 <br /> I tion laws of California." <br /> The ap t must c for all wired ins�t�iojn' Corbplete drawing on reverse side. "E - ��� <br /> Date: AJ <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Date '� Area <br /> Application Accepted by <br /> ate <br /> Pit or Grout Inspection by� <br /> Final Inspection by - Date <br /> Additional Comments: 1.. <br /> ElStk 466-6781 ❑ Lodi f 369-3621 ❑ Manteca 823-7104. ❑ Tracy -835-g85 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave,, P. <br /> Applicant <br /> 2009;Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH <br /> RECEIVED BY DATE PERMIY NO. <br /> + EH 13-24(REV. - <br /> EH W28 <br />