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/ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67B1 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> E (Complete in Triplicate) <br /> he <br /> rk <br /> . This <br /> cation is <br /> /or install t <br /> Application is hereby made to the San Joaquin Local Health District sewageo permit to <br /> construct62 forwe{!/pump and the Rhes and herein <br /> Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 <br /> I Local Health District. o t�Cizei PM <br /> r City 0� Lot Size <br /> Job Address '! 'e <br /> d@N Phone <br /> IC(S G IR Address C s pp <br /> i Owner's Name. t p 0,_3' 5 OY <br /> _ GI� I �^c) IB t,��0i14 �1� License No.�_��`�O Phone <br /> CfA� Address J <br /> Contractor 1 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: <br /> NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> _ SEWER LINES �--� DISPOSAL FLD. PROP. LINE <br /> DlSTANGE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL G <br /> ' INTENDED USE TYPE OF WELL <br /> PROBLEM CONSTRUCTION SPECIFICATIONS <br /> � EM AREA pia. of Well Casing <br /> Dia. of Well Excavation <br /> E Industrial [2 Open Bottom d Manteca Specifications <br /> Type LI Domestic I Private F-1Gravel Pack Ll Tracy of Casing Type of Grout--­ <br /> n <br /> rout -- <br /> n Other C1 Delta Depth of Grout Seal <br /> ('1 Public - _• ur! ce Seal installed by <br /> --Approx. Depth l-I East-_,Q__-�r,� <br /> I 1 Irrigation H P State Work Done <br /> I Repair Work Done ❑ Type of Pump -- Sealing Material flop 5l1') ti 1 <br /> Well Destruction ❑ Well Diameter - N <br /> f Depth r Filler Material (Belo 50') �] <br /> F available within 200 feet.! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.i REPAIR/ADDITION I DESTRUCTION I I {No septic system permitted it public sewer is <br /> ti Other=�--- <br /> Installation will serve: Resince t Commercial r <br /> k Number of living units: -,Number of bedrooms Water table depth , <br /> Character of soil to a depth of 3'et: No. Compartments <br /> Capacity— <br /> SEPTIC TANK_! P � ❑ Type7Mfg -tMet hod of Disposal <br /> l <br /> KG'TREATMENT F,kT. ❑ _ f `' Property Line <br /> I Well Foundation <br /> i Distance to nearest: � <br /> s Total length/size <br /> No. i <br /> LEACHING LINE Length of lines <br /> = O Foundation f(� '.Property Line <br /> t FILTER BED l; ❑ Distance to nearest:;, Well , <br /> ' 1 " <br /> r Number-- <br /> Size } k r ....— <br /> SEEPAGE PITS i I Depth <br /> t Foundation..-- x t Property Line, <br /> SUMPS ❑ Distance to nearest: Well x <br /> I DISPOSAL PONDS �..�k..-- +� <br /> I hereby certify that I have prepared this-application_and_that_the work will be done in accordance with San,Joaquin count�'ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local-Health District. l <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 shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California.,'shall Contractor's nslring or subject t workman'Iscompensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issu signature <br /> �d I shall employ p 1 <br /> tion laws of California." � <br /> . The applican`��all for all required ins ctions. Complete drawing on reverse side. i <br /> f �Jhl' Title: Date: •C " 1 <br /> I Signed <br /> R DEPARTMENT USE ONLY <br /> $ Date x° Area <br /> Application Accepted by +' ? <br /> Date <br /> Final Inspection by <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> ( ❑ Stk 466-6781 El Lodi :369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 �� <br /> _Applicant,.--Return all-copies-to:;Environmental 1-Iealth.PermitlServices 1{i01-E:-Hazelton Ave.-P-:O Box-2009�Sik:;GA,95201- <br /> FEE MOUN DUE AMOUNT REMITTED „ 5 RECEIVED BY DATE PERMIT'NO. <br /> INFO �}� t <br /> ., EH 1324(REV.i H 51 '��7%' �f <br /> EH t4-2e <br />