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APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRESA YEAR FROM DATE ISSUED C <br /> (Complete in Triplicate) application <br /> ,This <br /> Application is hereby made o 1 he Sin County Ordinance Health <br /> District <br /> for sewage r t to 1862 forcwell ldpump atnd the Rules and all the work herein <br /> ations of the SJoaquin <br /> u n <br /> made in compliance with Sanq <br /> Local Health District. �f <br /> k. City Lot Size PM <br /> Job Address &' �/ p <br /> r t4 ` Q _9 P11one� I Z a l7 <br /> Address <br /> Owner's Name U <br /> 4) _ e ,� ® (3� � �'` License No, Z3 73 —done d <br /> Contractor I•�,(�C�� Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />�. PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ + <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK —.�-- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Tracy Type of Casing Specifications � <br /> [3' omestic/Private ❑ Gravel Pack Depth of Grout Seal <br /> Type of Grout <br /> l ElOther ❑ Delta <br /> ❑ Publics" <br /> kedby <br /> rox.•De th.�❑-Eastern4" '-.�_.Surface-Seal-Instatl <br /> Repair Work Done ❑ Type of <br /> F <br /> ED Irrigation hof - 3 State Work Done <br /> H.P. _ r <br /> Pump Sealing Material {tap 50'1'• � <br /> Well Destruction El Well Diameter <br /> Depth I Filler Material (Below 501 <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A56 ITION ❑ DESTRUCTION ❑ aNaiiabpelwithin 200 feettted if public sewer is <br /> " Installation will serve: Residence— Commercial— Other�— <br /> Number of living units: Number of bedrooms Water table depth <br /> € Character of soil to a depth of 3 feet: 1 No. Compartments <br /> ❑ Type/Mfg Capacity <br /> SEPTIC TANK _' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ I Foundation Property Line <br /> Distance to nearest: Well r <br /> l I Total lengthlsize <br /> LEACHING LINE ❑ No. &'Length of lines Foundation : Property Line <br /> FILTER BED ❑ Distanceto nearest: ' Well <br /> I _ <br /> Size Number <br /> SEEPAGE PITS [I Depth Property Line <br /> I <br /> ` SUMPS w Ll Distance to nearest: Well <br /> Foundation <br /> DISPOSAL PONDS ❑ <br /> 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 District. <br /> work for Home owner olice n such manner sl not <br /> i s torbecome subjec�lto wlogkman'srtcampensation lfy that in the aewsoof Calrfo�niahB Cont actor which <br /> I or sub-contracting signature <br /> Home <br /> f employ any person <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 compen <br /> tion laws of California." <br /> r The applicant st call for all required 'nspections. mplete drawing on reverse side. <br /> Date: <br /> hGTtitle: <br /> Signed X ' <br /> f FOR DEPARTMENT USE ONLY <br /> { a, Area <br /> 1 Date <br /> Application Accepted by Date <br /> Pit or Grout Inspection by <br /> Date��� Final Inspection by <br /> r Additional Comments: © Manteca 823 7104 r❑Tracy 6355-6385` ¢`� <br /> f ❑ Stk 466-6781 Lodi 369-3621 O <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT <br /> FEE AMOUNT DUE AMOUNT RE MITTEfl CASH <br /> F INFO &A�3J� <br /> '+ EH 13-24 1 REV,1/615 - <br /> EH 14-26 <br />