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w APPLICATION FOR PERMIT w <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZELTON AVE.,.,S.TOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ,PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> --(Complete in;Triplicate) <br /> cation is <br /> San JoauinJoaquin County Loc ordinance No.649 for sewage Healt or permit <br /> No. 1862 forct and/or install th well/pump and Rules and e work herein <br /> Regulations of the San r Joaquin <br /> Application is hereby made to the <br /> madein compliance with San <br /> Local Health District: " { ' "e „ <br /> p PM <br /> Cry Lot Size <br /> Job Address <br /> Phone <br /> dress <br /> Owner's Namer <br /> r on <br /> ' ` 7 '. icense'No. <br /> Address w -_, .-.--•- - <br /> Contractor WELL REPLACEMEN ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> ` SEWER LINES DISPOSAL FLD. PROP. LINE <br /> TANK SUMPS <br /> DISTANCE TO NEAREST: SEPTIC OTHER WELL— <br /> FOUNDATION <br /> FOUNDA710N _—� AGRICULTURE WELL "•_---�^�°"' <br /> l ----- -TYPE`OF'WELL PROBLEM AREA—CONSTRUCT CiF1CATIONS <br /> ...-- _--1NTENDED-USf �J Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Type of Casing Specifications <br /> ❑ Tracy - - <br /> ❑ Domestic/Private ❑ Gravel Pack 1-1Delta Depth of Grout Seal Type of Grout <br /> ❑ Public ❑ Other ` <br /> � <br /> pprox. Depth El Eastern Surface Seal Installed by <br /> ❑ Irrigation r H P State Work Done— <br /> Repair Work Done ❑ Type of Pump <br /> p 54 <br /> Sealing Material I� '1 i <br /> Weil Destruction ❑ Well-Diameter el, <br /> Depth I Filler Material {Below 50'1 <br /> tic system permitted if public sewer is <br /> available within 200 feet.} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ flEPAIRIADDITION ❑ DESTRUCTION# � �PI I <br /> Commercial— Other�� 1 <br /> I Installation will serve: Residence� _ 1 <br /> Number of bedrooms-- <br /> Number of living units: a. �,.� , , �*1 L Water table depth <br /> r Character of soil to a depth of 3 feet: 1 Capacity —B — No. Compartments <br /> SEPTIC TANK ❑ Type/N�fg Method of Disposal <br /> i I <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest- Well <br /> I � <br /> t S" Total length/size. <br /> LEACHING LINE ❑ No. &l Length of lines: 1. Property;Line <br /> y t x ', Foundation—� <br /> FILTER BED H ❑ 'Distance to nearest: Well t <br /> ' t i <br /> Number <br /> Depth Size { <br /> SEEPAGE`PITS Foundation Property-Linen <br /> r <br /> LJ Distance to nearest:- Well . <br /> F SUMPS <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sa Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.g certify> work for <br /> Home owner or licensed agent's signature certifies the follo wiorkman'sompensation laws that in the of.California." Contractor's(hir hiring opsub-contractirmit is s glsignatushall re <br /> employ any person in such manner as to become subiect toeesons sub'ect't6workfnan's compensa- <br /> certifies the following: "I certify that in the performance of the work for which'this permit is issued,I shall employ p 1 Y <br /> laws o Califor <br /> 1 <br /> applic Ust call fo 11 r.. vire i pec . Complete drawing on reverse side- �� .✓ k '�t r _ (] <br /> Date: <br /> Title: <br /> [ ;gne <br /> FOR DEPARTMENT USE ONLY r-- <br /> Date Area <br /> I- Application Accepted by ur <br /> Final Inspecon by Data <br /> Pit or Grout Inspection by <br /> Date—..�-- ti <br /> Additional Comments: l <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104. [1 Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409. Stk., CA 95241 <br /> BY DATE PERMIT NO. <br /> FEE AMOUNT DUE -AMOUNT REMITTED"JE!RECEIVEDINFO �0 �r-��4s gsl Llay <br /> �n <br /> + EH 1324(REV. /x 5l .. <br /> EH 14-28 <br />