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APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ' PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> cation is <br /> Application is hereby made SanJoaquinu n County ordinance lfNth.5 District for sewage or it t 1 on forcwe Ildpump and the Rules and/or in'stall the work tRegulations of n described. tlhe Sanis s Joaquin <br /> made in compliance with q n� <br /> Local Health District. <br /> City <br /> Lot Size PM <br /> Job Address IZMme <br /> "?J .� Phone <br /> t Address <br /> Owner's Name �J ' <br /> y ' license No.��Phone b , <br /> Contractor 1h� tLn � C ddress <br /> WELL DESTRUCTION ❑ <br /> r HEW ❑ WELL REPLACEMENT LJTYPE OF WELL/PUMP: SYSTEM REPAIR 13 OTHER ❑ M <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES __—_-- DISPOSAL FLD. a PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE _ TYPE OF WELL <br /> PROBLEM CONSTRUCTION SPECIFICATIONS <br /> EM AREA pia of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications — <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Type of Grout <br /> ❑ Public rl Other r (I Delta r _ <br /> f Approxi, Depth I 1 Eastern Surface Seal Installed by <br /> I I Irrigation ..r State Work Done <br /> Repair Work Done ❑ Type of Pump ,.H.P, t <br /> fi , t <br /> R <br /> well Destruction ❑ Well Diameter ' <br /> Sealing Material (top 50'1 I <br /> ;,.a.,.�.f cl r � Depth T( � Filler Material (Below 50'1 {� <br /> TION I EPAIfl/ADDITION Ll DESTRUCTION l 1 (No:septic system Permitted if public sewer is <br /> NSTALLA ilable with <br /> TYPE OF SEPTIC W <br /> ORK: NEW I ova \\ <br /> Installation will serve: Residence 'Commercial fler <br /> Number of living units. Number of bedrooms ; <br /> i Water table depth <br /> Character of soil to a depth of 3 feet: #" t f ap'acity� No. Compartments <br /> IYPe/Mfg <br /> I :�_` <br /> SEPTIC TANK A�Cof Disposal c <br /> PKG. TREATMENT PLr e 1 -T. ❑ Foundationit Property-Line iVJ��JJ <br /> a Distance to nearest: Well f <br /> .- e s - l Total length/size <br /> LEACHING LINE Elmo. & Length of lines , <br /> Foundation Property Line <br /> FILTER BED 0 Distance <br /> to nearest. Well S O 41 . <br /> - 11 <br /> 4 Number <br /> SEEPAGE PITS d---Depth 5__S ize „{ <br /> Foundation t r Property Line <br /> SUMPS L1 Distance to nearest: Well r �G1 - <br /> DISPOSAL PONDS ❑ !J <br /> w <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 /> y that in the performance of the work for which this permit is issued, !shall not <br /> Home owner or licensed agent's signature certifies the following: "I certif <br /> employ any person in such manner as become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ <br /> Zap <br /> person i 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 /> followi <br /> r_ tioalif ia." t <br /> j Tht m t'calf oral rem let drawing on r11 <br /> arseSi <br /> E FO MENT USE ONLY <br /> q _-- Date �~ �bArea <br /> Application Accepted by <br /> Date <br /> Final Inspection by <br /> Pit or Grout Inspection by Date <br /> i Additional Comments: <br /> ❑ Stk 466-6791 ❑ Lodi 369-3621 Applicant <br /> 623-71f)4 ❑ Tracy 635-63135 <br /> °a Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .,,,Y,.CK -RECEIVED;9Y,— DATE„" PERF/IIT''NO." <br /> FEE.r.,:..,- OUNT-DUE'^^!" ---AMOUNT" CASH <br /> INFO <br /> r EH 1324(REV.t i H 5) <br /> EH 14-2a <br />