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APPLICATION FOR PERMIT <br /> AV— ! f� �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT (� <br /> `—C b k <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATEgISSUED <br /> � 1^ k) <br /> R . (Complete in Triplicate) .This I�cation is { <br /> /or install the work <br /> gpplicatto <br /> n is hereby made to the San Joaquin Local Health District for sewa permit <br /> No. 1862 for wellldpump and the Runes and IR Regulations of the San Joaquin <br /> made in compliance with Sari Joaquin County Ordinance -� <br /> ocal Health District. <br /> city PM <br /> Lot Size <br /> �� .• . <br /> Job Address140 <br /> �. Phone <br /> Address <br /> Owner's Name] I <br /> ` 'r ` License No. ---Phone_ <br /> L 1- tt Address <br /> ontractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑,r OTHER-0 <br /> SYSTEM REPAIR ❑ PROP LINE <br /> - PUMP 1NS7ALLATION ❑ 1� DISP <br /> SEWER LINES PITSISUMPS <br />! DISTANCE.TO.NEAREST: SEPTIC TANK --- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> STRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA Dia. of Well Casing <br /> Dia. of,Well Excavation. <br /> ❑ industrial ❑7pen ❑ Ma Specifications 1 <br /> Tracy Type of Casing V� <br /> 0 Domestic I Private " Type of Grrut <br /> F] Delta Depth of Grout Seall'1 Public CSurface Seal Inslailed liy <br /> I I irrigationth l I Eastern State Work Done <br /> Type of Pump H.P. <br /> a Repair Work Do Sealing Material (top 50'l <br /> ' 1 Well Destr ction ❑ Well Diameter C <br /> s Filler Material iBelow-50`1 <br /> Depth <br /> n available within 200 feet.] <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlADDITIDN l 1 pESTRUCTION INo septic system 77111 permitted if public sewer 1s <br /> Installation will serve: Residence, Commercial Other 'Y i <br /> Number of living units: Number of bedrooms Water table depth <br /> I Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal, 1 <br /> ? PKG. TREATMENT PLT. ❑ Propdrty~Line <br /> Distance to nearest: well <br /> Foun aatiori <br /> Total lengthlsize <br /> LEACHING LINE ❑ No. &Length of lines Property Line <br /> ❑ Distance to nearest: Well' 'Foundation p y <br /> FILTER HED .I <br /> Size Number <br /> SEEPAGE PITS l 1 ,.'Depth <br /> it Property Line <br /> SUMPS L) .Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS 4 T <br /> i application <br /> and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this app- <br /> rules and regulations of the San Joaquin Local Health District:a performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the ft to <br /> I certify that in the pe ers's h subject to workman's compensa <br /> employ any person in such a that s to become n the performance cofothe wok for which this permit is issued, I shall employ Perron hiring or so workman's-contractinsignature <br /> certifies the following <br /> tion laws of California." <br /> applicant must call for all re ired inspections. Complete drawing on reverse side. <br /> The app i Date: <br /> � ..- � Title: <br /> Signed X; <br /> FOR DEPARTMENT USE ONLY i <br /> Date f 41 Area <br /> Application Accepted by ;" Date - <br /> Date�_�— F a Inspection Y <br /> Pit or Grout Inspection by - <br /> I it <br /> Additional Comments: ❑ Manteca a23-711)4 ❑ Tracy 835-6385 <br /> © Stk 466-6781 ❑ Lodi.l 3621 <br /> Applicant- Return ail copies t Envir nmeT,, <br /> Weal��rmiyt,rv�ice601 E. Hazelton Ave., P.O. Box?0�9, Stk., CA 95201 <br /> I( r f/ If `J ��,�'J[(,.w PERMIT'NO. <br /> RECEIVED BY <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> DATE <br /> INFO v/!IUQ <br /> Y ♦.EH13-241pEV.t/>t51 '�� ��"� /�L / - <br /> EH 14-48 <br />