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APPLICATION FOR PERMIT <br /> ' SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE`'-.TON AVE., STOCKTON, CA <br /> J Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED - # <br /> (Complete in Triplicate? thcation is r <br /> 2 for welI/pump and the flutes and Regulations of the San Joaquin <br /> i <br /> San Joaquin Local Health District for a pe or No. <br /> lggstruct and/or install the work herein described.-7h+s app <br /> Application is hereby <br /> made to the Sa for sewag y, <br /> made in compliance with San Joaquin County ordinance No <br /> r - rs PM--r <br /> Local Health District. y Lot Size f <br /> r7'ICI City <br /> ! ) <br /> pr <br /> Phone ' <br /> Job Address <br /> wl - Address <br /> VV1 e Phone <br /> Owner's Name License No. <br /> Address DESTRUCTION ❑ <br /> Contractor WELL REPLACEMENT ❑ OTHER ❑ <br /> TYPE OF WELLlPUMP: .. �,, -'WELL L7.! SYSTEM REPAIR ❑ <br /> PROP. LINE <br /> .q PUMP:INSTALLATION ❑ t "� DISPOSAL FLD._1 <br /> SEWER LINES _� PITS/SUMPS <br /> DISTANCE TO NiST= SEPTIC TANK �� AGRICULTURE WELL" <br /> OTHER WELL <br /> FOUNDATION �— t <br /> PROBLEM Eq CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �g <br /> INTENDED USE TYPE OF jWEtt Manteca Dia- of Well Excavation Specifications <br /> ❑ industrial ❑ Open Bottom Type of Casing1. <br /> Type of Grout <br /> ❑ Gravel Pack ❑ Tracy <br /> ❑ Domestic/Private ❑ Delta Depth of Grout Seal <br /> ❑ Other `� 1 Surface Seal installed by <br /> ❑ Public ��pprox. Depth ❑ EasIerri { State Work Done— <br /> i 'H.P. 1 <br /> i ❑ irrigation f <br /> 4 Repair Work Done ❑ Type of Pump s - <br /> Sealing Material flop 50'I # <br /> Well Destruction ❑ Well Diameter Filler.Material (Below 50'1 ermitted if public sewer is <br /> Depth DESTRUCTION 1No septic system p <br /> j �. available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ <br /> µ Commercial Other 0 ' <br /> Installation will serve: Residence Water table depth <br /> Number of living units:" r Number of bedrooms 1i" <br /> { Character of soil to a depth of 3 teat: 4 j Capacity, --� <br /> No. Compartments <br /> l ❑ Type/Mfg Method of Disposal <br /> SEPTIC TANK µ <br /> 4 PKG. TREATMENT PLT.❑ Foundation�� Property Line—�� <br /> Distance to nearest: Well <br /> t ' Totallengthlsize <br /> i= LEACHING LINE ❑e No, & Length of lines ° Property Line <br /> ❑ Distance to nearest: Well Foundation r-�— <br /> FILTER BED <br /> Number <br /> ❑ Depth r Size Property Line <br /> SEEPAGE PITS ' i Foundation <br /> SUMPS ❑ Distance to nearest: Well r <br /> ❑ � <br /> DISPOSAL PONDS ` <br /> hereby certify that I have prepared this application and that,the work will be done in accordance with San Joaquin county ordinances, state Iasha an <br /> not <br /> I he Yk for <br /> certify that in i he laewsoof iiinCe of the w Contractor's s�hir g ors b-con act ngis'Issued, l Signature <br /> rules and regulations of the San Joaquin Local Health District:-�-� � <br /> Home owner or licensed agent's signature certifies the following: " rsons subject to workman's compensa- <br /> employ any person in such manner as to become subject to workman's camp <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ pe <br /> F <br /> tion laws of California." S <br /> The applicant must all for all required in ctions.IComplete drawing on reverse side. <br /> Date: <br /> Title: ? <br /> Signed t � -" <br /> FOR DEPARTMENT USE ONLY �sr.- <br /> Area <br /> fjl'3�4ffi- <br /> Dte //Application AccBp by t `` L�.( i- /,d Date� �tal lnspction by <br /> at <br /> Pit or Grout Inspection byAdditional Comments: ❑ Tracy 835r�`❑ Stk 466-6781 ❑ 1 ❑ Manteca 823 7 04 <br /> Applicant Return all copies to: Environmental Health,Permit/Sarvic Is 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ' � pERMlTN0. <br /> rt C RECEIVED BY DATE <br /> } FEE AMOUNT DUE AMOUNT-REMITTED' S ` <br /> } INFO i )�130� �SS A J <br />