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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> - Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> .(Complete in Triplicate) on is <br /> in Local Health <br /> Application is hereby <br /> maith a to the San County Ordnance No.District permit herein <br /> 549 for sewage or No.,1862 for well//pump and the Rules and R gulations of he Sant Joaquin I <br /> nce <br /> made in comp <br /> Local Health District. " ... <br /> (i, 1 City Le A �_— Lot'Size 1346 PM <br /> Job'Address <br /> 1 4 Phone 54 9 �P-3 <br /> � L. h, <br /> w _Ii <br /> 3 Address <br /> Owner's Name 1``t <br /> 97 <br /> N, 1r ' ` � V P C, U ll-le- o f `Phone - <br /> Contrac'tor's Name — Luov _ _license Na _ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION!❑ f ,, <br /> PUMP INSTALLATION ❑ -,-.y `I `SYSTEM REPAIR ElOTHER,O �✓, ; <br /> SEWER LINES DISPOSAL FLD. PROP:.LINE <br /> DISTANCE TO NEAREST: SEPTIC:TANK1. �_---.._ . ,✓� OTHER WELL ' PITS/SUMPS <br /> t FOUNDATION _ AGRICULTURE WELL 4 T w t <br /> -�INTENDED USE' TYPE OF WELL - PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia:,of Well Ezaavation k ! Specifications <br /> ❑ Trac Type'of [ <br /> ❑ Domestic/Private ❑ Gravel Pack-Ill. <br /> y Type of Grout <br /> ❑ Other .❑ Delta Depth of Grout Seal1 <br /> ❑ Public <br /> ❑ Irrigation ----Approx. Depth`L. Ll Eastern Surface Seal Installed by <br /> `':' u� State Work Done 1 <br /> Repair Work Done ❑ } Type of Pump �I,,.H.P. <br /> 5 �= '�� Sealing Material [top 50'1 <br /> Well Destruction ❑ Well-Diameter Depth `; , S <br /> ; �� ^; CFiller Material-[Below 50'1 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION:❑ REPAIR/ADDITION 1 DESTRUCTI ❑ availablie{with nepermitted 200 feet.) if public sewer {s <br /> installation will serve: Residence Commercial Other_-- <br /> if Number of be — 1 <br /> Number of living units: ;r_ Water table depth <br /> Character of soil to a depth of 3 feet: Capacity f No. Compartments <br /> Type/Mfg 1/?�'��L /' <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> F Distance to nearest: , ,Well <br /> Foundation Q Property Line <br /> Total length/size XZ <br /> LEACHING LINE . [� No. & Length of lines; o <br /> i z Foundation 7� Property Line <br /> FILTER BED ❑ Distance to nearest: .k Well a <br /> mbe <br /> Nur <br /> SEEPAGE PITS Depth 'I Size_ 3 i ° <br /> Foundation � Property Line �!7 <br /> SUMPS El Distance to nearest: Well �' d - `� <br /> DISPOSAL PONDS ❑ <br /> I hereby,certify that-1.haVe prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> l rules and regulations.of the San Joaquin Local Health District. c , <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 signature <br /> shall not <br /> ion <br /> certifies ring or sub <br /> poy any the personfollowing 1 oerna that in toe performance of subject othe wok for which this sperm permit issued,of fI shall empoy.pbrsons'subj subject t workman's-contracting <br /> tion laws of California. _ <br /> The must call for all r quired inspectio . Complete drawing on reverse side. <br /> �.- --- -.-..- .._... ..-. -— ^ ., Date: �+ <br /> Title: <br /> � <br /> Signed R ., <br /> +, 'FOR.DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by _ w. <br /> _ �— Date <br /> �s Date Final Inspection by �-- <br /> it r Grout Inspection <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca ffi3-7104 Q.Tracy 835-6385 95201 <br /> GA, <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601-E.'Hazelton Ave., P.0 Boz 2009. Stk. <br /> y CK RECEIVED BY DATE PERMIT"NO" <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24{REV.401$31 <br /> EH 14-28 {{{ <br />