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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> :PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i1; (Complete in Triplicate) <br /> made n the Joaqu <br /> in u+ordinance Nth District for a o.549 for sewage or t to No. 1862 for construct and/or <br /> and the Rules and'R Regulations. This Ofof the Sancation is <br /> Joaquin j <br /> Application is he+eby �(i <br /> made in compliance with San Joaqu+ f� tY 7'7 <br /> Local Health District. . <br /> City <br /> Lot Size PM <br /> CJ i <br /> Job Addres e Z!Z <br /> AddressOwner's Nam 0AddressLicense No. Phone ! <br /> Contract WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> F PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE O3WELL �--� Dia. of Well Casing k <br /> Dia. of Well Excavation <br /> ❑ Industrial <br /> El Open Bottom ❑ Manteca Specifications <br /> + Type of Casing <br /> ❑ Domestic)Private C1 Gravel Pack ❑ Tracy Type of Grout — <br /> F Other . Cl Delta Depth of Grout Seal <br /> } Public Surface Seal installed by <br /> I'I Irrigation w o-' --ApP+Qx• Depth 11'£astern State Work Done <br /> ' H.P. <br /> Repair Work Done ❑ TEEEEE�� 7 <br /> ype of Pump Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material (Below 50') <br /> I <br /> o available within 200 feet.) <br /> TYPE OF 5EPTlC WORK: NEW t R[PA'IRIADDITION I-I -DESTRUCTION l 1 (No septic system permitted'if public sewer +s <br /> Commercial�.� Other - a. <br /> Installation will serve:. Res ence� <br /> Number of Living_units:- Number of edro ms -�- ""' Water table depth <br /> —L~Character of soil to a depth of 3 feet: + No. Compartments <br /> T e/Mfg Capacity G <br /> l <br /> SEPTIC TANK � Yp f � Method of Disppsal <br /> PKG. TREATMENT PLT. ❑ i -- 1 WellFoundation L� Pro ert <br /> Distance to nearest: <br /> rR <br /> r ,� Total length/size Q x1 <br /> I LEACHING LINE No. & Length of lines <br /> FILTER BED ❑ Distance to nearest:- Well_`J�— <br /> Foundation -� Property Line <br /> } ir <br /> ' <br /> i SEEPAGE PITS Depth t Si <br /> ze t <br /> j"FouQ-- Line <br /> SUMPS Ll Distance to nearest: Well :- ndationProperty <br /> + i� + �1 <br /> DISPOSAL PONDS.. ❑ <br /> 1 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 /> Y <br /> Home owner or licensed agent's signature certifies.the following: "I certify that in the performance of the work for which this per <br /> is issued, l she not <br /> I employ any person in such manner as to become-subject to workman's compensation laws of California." Contractor's 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 employ persons subject to workman's compensa <br /> tion laws of California." - / '' <br /> applicant mu cab for all r <br /> ire- inspections. Gomplate drawing on reverse-side L' <br /> The app- � � Date <br /> Title: <br /> Signed X <br /> FOR DEPART ENT USE ONLY, <br /> /. <br /> a � k Data <br /> Area <br /> Application,Accepted`by 4 ` $'r <br /> `j �'`: „_� f • Date <br /> Final Inspection by <br /> Pit or Grout Inspection by T ,f]ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823=7104 ❑ Tracy X835 6385 3 <br /> lth Permit/Services 1601'E.�NeNeieltonRAva., P.O.,Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Hea <br /> CK RECEIVEDi,-ijY 4 > DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH �' <br /> INFO <br /> i <br /> +.EH 13.24(REV.+/a 5) r <br /> EH 14-2e <br />