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L� � <br /> APPLICATION FOR PERMIT <br /> SAN JOAO:UIN .LOCAL HEALTH DISTRICT W,E- ,xy.` <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 �)..�. <br /> -PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)n Local Health <br /> ll the work herein <br /> .This <br /> is <br /> Application is lhereb with a to the San Joaciu, <br /> n County ordinance No.District549 far sewage or Permit <br /> Noo 1862 for construct <br /> ell/dpump and the Rules and Regulations of the Sar Joaquin <br /> n <br /> made in comp <br /> Local Health District. - / <br /> y0 t 7! "� City ST�C1J/Lot Size l PM <br /> .fob Address t <br /> �•%.¢�� Address Phone r <br /> Owner's Name —1--, f <br /> t Phone <br /> Contractor �_/� <br /> Address License No. —_-- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER 11 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS _ <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing d <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack EI Tracy Depth of Grout Seal Type of Grout j <br /> ❑ Public Q Other ❑ Delta <br /> C] Irrigation �Approk: Depth ❑ Eastern Surface Seal Installed by <br /> H.P. <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump Sealing Material ltop 50'} • Y <br /> Well Destruction ❑ Well Diameter g �- <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ f.DESTRUCTION (No septic system permitted if public sewer is <br /> .c.A <br /> vailable within 200 feet.) <br /> I <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth /Y <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity_ <br /> SEPTIC TANK ,Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> ,I <br /> Total length/size <br /> f LEACHING LINE ElNo. & Length of lines Property Line <br /> FILTER BED <br /> CJ Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS 13 Depth; <br /> ' + R. <br /> 4' ' Foundation Property Line <br /> SUMPS 11 Distance to nearest: Well: ' <br /> DISPOSAL PONDS ❑ 11 <br /> ~ this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> I hereby certify that I have prepared 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 the work for which this permit is issued, L signature <br /> shall not <br /> ion <br /> certif�es any the fo following:such <br /> certify that n the performancecofthe wok for which <br /> his tpermitvis issuof ed,I rnia."Contractor's shall employ persons'ring or subj subject t workman'socompensa- <br /> I g: <br /> tion laws of California." i.1 <br /> The appy ant serse side. <br /> t all f r all requir ins coons. Complete drawing on revue / <br /> Title: Date: <br /> ,Signed 7 ` <br /> � ORDEPARTMENTUSE ONLY <br /> Date <br /> Application Accepted by <br /> � i <br /> Date Final Inspection by <br /> Date <br /> Pit or Grout inspection by fr 1%-A �< <br /> 1%-AA <br /> ' Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CI Tracy <br /> ' Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> rCK REGEIVED 6Y DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 187 <br /> S + EH 13.24(REV.1 a b) 3 p <br /> EH W28 ` � <br />