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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELION AVE., STOCKTON.,.GA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED f <br /> (Complete in Triplicate) <br /> cation is <br /> Application is herebyM <br /> lor <br /> ma a to the <br /> Joaquin County Ordinalnce No.549 for sewage o permit No. 1862 for weld <br /> aquinHealth District for a well/pump install' nd the Rules and Regulations of he San s Joaquin <br /> ith <br />,. <br /> made in compliance <br /> Local Health District.n it <br /> s� <br /> City Lot Size PM <br /> Job Address <br /> Phone <br /> Owner's Name <br /> �/� �,xa MILE Address , <br /> Contractor �_�5rL7 Er Address <br /> License No. �� 7!o Phone �- <br /> NEW WELL ID WELL REPLACEMENT LJ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER D <br /> PUMP INSTALLATION El <br /> lSEWER 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 Specifications <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation h <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ii Type of Casing Type of Grout <br /> ❑ Delta Depth of Grout Seal <br /> [I Public Other `.It i - <br /> 1 1 Irrigation —.-Approx. Depth [ I Eastern Surface Seal Installed by <br /> ,H.P. State Work Done — <br /> Repair Work Done 0 Type of Pump r <br /> Sealing Material Itop 501 <br /> Wel[ Destruction ❑ Well Diameter i- <br /> Depth 1 Filler Material [Below 50'! <br /> III TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION LI DESTRUCTION [ I ( c SY <br /> No septiwi within 200 feet.) if p �public sewer is r <br /> installation will serve: Residence/ Commercial F Other <br /> Number of living units: __L_ Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ��p No. Compartments 7 <br /> SEPTIC TANK ; Type/Mfg t� Capacity i <br /> Method of Disposal <br /> I - PII TREATMENT PLT. ❑ / © <br /> Distance to nearest: Well Q <br /> Foundation 140 Property Line <br /> # r Total length/size <br /> LEACHING LINE No- & Length of lines z f <br /> FILTER BED r+ ❑ 'Distance r Property Line to nearest: Well_ !Z— Foundation <br /> z - <br /> _ Numher <br /> ----'.{.u. - <br /> SEEPAGE PITS [ l j Depth} Size <br /> I ❑ Distance to nearest: Well Foundation P aperty Line <br /> SUMPS <br /> DISPOSAL PONDS ❑'. <br /> I hereby certify that I have prepared this application and that'the work will be dona,in accordance with San jaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.7 ;7 r tha,t in the performance of <br /> ,� k ch <br /> i Home owner or licensed agent'ssignattire certifies the following:.'',) certify the.work for vvhlcthis permit is issued, I shall not <br /> r <br /> manner:as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in`such <br /> certifies the following: "I certify that iri the performance of the work for which this permit is issued; I shall employ persons subject to workman's compensa <br /> tion laws of California." 1� <br /> The applicant must call for all requirad_inspections: Complete drawing on reverse side. 1 <br /> '- ' ate: <br /> ' t-,- Title: z . <br /> Signed'X v <br /> I 'FOR DEPARTMENTXSE-ONLY <br /> t k ;�• Date \0 3a Area <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments; <br /> Stk j466-6781 ❑ Lodi 369-3621 ❑ Menteca y-.a23-7104r _ ❑ Tracy 835-6385 K <br /> plicant - Return all copies to: Environmentai Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, St�k., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDrRECE1VfD BY DATE aMM NO, <br /> INFO T t /♦ EN13-241REVII/II � -7h4 <br /> + -EH 14-25 <br />