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APPLICATION FOR PERMIT <br /> t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> �jPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i (Complete in Triplicate) <br /> permit to construct andlor install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a p and the Rules and Regulations of the San Joaquin <br /> 9 <br /> made a compliance Ma.San Joaquin CoL;nty Ordinance No.549 for sewage or No. 1862 for we111pump ` <br /> ith <br /> Local Health District. \1�-1� CZE � - <br /> 1 City Lot Size d9-7— PM <br /> Job Address <br /> Address phone <br /> Owner's Name <br /> License No-- Phone_ <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL SYSTEMOTHER ❑ <br /> PUMP INSTALLAATIONI ,�rREPAIR ❑ <br /> NEAREST: SEPTIC TANK f SEWER LINES _ts�—�— DISPOSAL FLD�.I�fr�� PROP. LINE <br /> DISTANCE TO --N ATION _�_ AGRICULTURE WELL 00&r:,_ OTHER WELL 1► PITS/SUMPS >� <br /> FOUR <br /> kNTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D.a._of <br /> Oen Bottom ❑ Manteca Dia. of Well Excavation, w-� �} <br /> ❑ industrial p Specifications <br /> Type of Casing 5 f1 <br /> �DomesticlPrivate 1�Gravel Pack Ll Tracy yp Type of Grout - /7• <br /> Other f.1 Delta Depth of Grout Seal ll <br /> I`1 Public Surface Seal installed by <br /> I I Irrigation - <br /> Approx. QepCt�h, l I Easternr State Work Done <br /> Repair Work Done <br /> Type of Pump'll�� H.P. r <br /> Sealing Material Itop 541 <br /> Well Destruction ❑ Well Diameter r Filler Material [Below 50'I <br /> Depth . <br /> available within 204 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIQN I i REPAIRlADDITIDN I I DESTRUCTION+ I ave(No septic system permitted it public sewer is <br /> installation will serve: Residence <br /> Commercial Other <br /> Number of living units: Number of bedrooms � v r,r +• •.Water table depth <br /> Character of soil to a depth of 3 feet: Capacity's No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg I M Method of Disposal ' <br /> PKG. TREATMENT PLT.LIr Property Line <br /> Distance to nearest: Well Foundation <br /> i <br /> Total length/size <br /> F LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> El Distance to nearest: Well Foundation P y <br /> r <br /> Size, � Number <br /> l'. SEEPAGE PITS V I DepthFoundation Property Line <br /> SUMPS Ll Distance to nearest: Well <br /> 1 DISPOSAL PONDS ❑ <br /> I I 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 Di$trict. work <br /> nce of Herne owner or licensed agent's negas tol not <br /> rbecome subjects to workman's kman'srtcompensation Iify that in the la s of California." Contract or'srhiri gI or sub cont acti grmit is issued, lsgnlaturre <br /> employ any person in <br /> certifies the following: u certify that s 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 /> The applicant ca for all required inspecti ns. Complete dr Ing on reverse side. <br /> Date: <br /> L Title: <br /> Signed X <br /> € FOR DEPARTMENT USE ONLY <br /> M Date Area �t <br /> I Application Accepted by f <br /> i Pit Grout nspection by Date <br /> �+-11 Final Inspection by Date <br /> r <br /> Additional Comments: r <br /> ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 <br /> ' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> 1PERMIT'NO. <br /> CK RECEIVED By DATE <br /> FEE AMOUNT.DUE AMOUNT REMITTED CASp <br /> INFO <br /> r.EH 13-24(REV. H 5 ,v t/"✓ <br /> EH 14-26 __ <br />