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APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or <br /> cation is <br /> Application <br /> in with SanJoaquin Iphron County ordinance No. 549 for sewage Local <br /> Local <br /> permit <br /> 1862(or install <br /> well/pump nd the Rul s and herein <br /> Regulations of the San l <br /> or Joaquin <br /> mad <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address � /�`d - �} <br /> �4�t�s Phone <br /> Owner's Name oy <br /> Contractor <br /> AddressLicense N U Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ OESTRUCTiON � ulP� S <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> --FOUNDATION" AGRICULTURE WELL OTHER WELL PITSISUMPS � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> E2 Industrial ❑ Open Bottom E3 Manteca a Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack d Tracy Type of Grout <br /> F1 Other j ❑ Delta Depth of Grout Seal _ <br /> FI Public — f i c \ <br /> I 1 Irrigation, _Appfox-!,Depth I 1 Eastern Surface Seal installed by <br /> t P State Work Don <br /> Repair Work Done L7 Type of Pump (/H <br /> t Well Destruction �u" <br /> Well Dia ete� ��Sealing Material Ito p 50'1 �G7 % QC/' awe <br /> Depth " 49 Filler Material (Below 50'1 L � <br /> \T.YPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIRIADDITION l I DESTRUCTION l._l availablelc system-w thin 200 feet.) public sewer is t� <br /> r `\ <br /> Installation will serve: Residence J Commercial Other <br /> l ` Number of living units: c Number of bedrooms <br /> " Water table depth <br /> !f Character of soil to a depth of 3"feet: <br /> 4Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> " PKC. TREATMENT PLT. ❑ <br /> ' Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size " <br /> I - -°Property Line' <br /> FILTER BED-T-^^"v —"❑ `Distance'to-nearest: y well-.2 """- Foundation <br /> SEEPAGE PITS I I Depth ° Size <br /> Number <br /> 1 ' Foundation Property Line <br /> t SUMPS L� Distance to nearest: Well <br /> DISPOSAL PONDS ❑ 1 ° <br /> ith San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work will be done in accordance w <br /> rules and regulations of the San Joaquin Local Health Di1trict. <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, I shall not <br /> 1 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." °I <br /> I The applican u requ' ons. Complete drawing on ev side. <br /> Signed X <br /> Title: Date: <br /> /nom FOR DEPARTMENT USE NLY +� I <br /> I /�'/ Area <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> ! Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, S1k., CA 95201 <br /> FEE r CK RECEIVED BY DATE PERMIT"No. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EH 13.21(REV.1/8 5i <br /> S �S� roc jf <br /> EH 11-26 <br /> t <br />