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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) <br /> all the work <br /> . This <br /> cation is <br /> made in compliance with Sanmade othe Joaquin nJoaquin County ordinalnce Nth District for a o,549 for sewage or permit <br /> No. 1862 for we Iipump atnd the Rules and IR Regulations of the San Joaquin <br /> Local Health District. <br /> City VL2 4 'Size '� E PM <br /> Job Address r3 — <br /> dress <br /> �� - Phone r r <br /> Owner's Name <br /> ;C 7 l _ License No. , Phone <br /> Contractor Address _ <br /> TYPE"OF-17VECL/PUhAP �EGti11NECC"❑.T�.�"�"WELL fiEP-CA�EMt=f`]�'"f�� _DES�C1�Ti6�f�T�'.�._...:, ^-�..-._. <br /> PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �'> <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS��.,�.-_-_..__ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation I Dia. of Well Going <br /> 1 Specifications <br /> ❑po�estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Depth of Grout Seal Type of Grout <br /> fl Public 171 Other 171 Delta <br /> I I Irrigation --Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair,Work Done ❑ Type of Pump H.P. State Work Done <br /> _ <br /> Sealing Material Itop 50'1 ; <br /> Well Destruction ❑ Well Diameter 9 <br /> Depth Filler Material (Below 50'1 <br /> TYPE;OF SEPTIC WORK: NEW INSTALLATION EPAIHIADDITION I 1 DESTRUCTION I i (No septic system permitted if public sewer is <br /> i <br /> available within 200 feet.I <br /> Installation will serve: Residence`_Commercial— Other — <br /> Number of living units: —/— Number of bedrooms _.— <br /> Wate table depth r� <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK f;1/rype/Mfg �Caity_� Q�.-- Na/Compartments } <br /> PKG. TREATMENT PLT. ❑ /Method of Dispa�sal <br /> Distance to nearest: Wei 'l�( Foundation ��� —"Pro✓perty Line <br />' / "" _. ter. <br /> t tel ken th/size <br /> LEACH�ING LINE {eY iVO. & Length of lines — T� a <br /> FILTE!R;.BED ❑ Distance to nearest Wei _ Foundation //S�"4' Property Line g <br /> SEEPAGE PITS KL Depth �/- --Size_,"eg � Humber t <br /> SUMPS ❑ Distance to nearest: Well f . ~ Foundation -- Property Line � - <br /> DISPQ,SAL PONDS ❑ <br /> 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 f r <br /> rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I sN not ,< <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifiers the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to work-man's corripensa <br /> tion laws of California." (j �• <br /> The applicant call for a all requir inspections. Complete drawing on reverse side. I <br /> y I Title: <br /> ned Date:-- _ .. <br /> SigX r i 1 , <br /> FOR DEPARTMENT USE ONLY T <br /> �; ' i Date rea' <br /> Application Accepted In ` I R <br /> —a-,�j ' <br /> }} ff Date-1 -�Q c+ <br /> Pit oT,Gout Inspection - Date _ Final Inspection by <br /> _ # —i <br /> irk <br /> Additko I,�Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 ❑ Man eca 523-7104 `❑ Tracy 835-6385 <br /> 4 Applicant Return all copies to: Environmental Health P rmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., C 01CK 4 <br /> i V <br /> FE£ AMOUNT DUE AMOUNT EMITTED CASH <br /> RECEIVED BY DATE ': PERMIT"NO. <br /> INFO ` ry :v _N1 <br /> ♦.EH 13-241REV.r/85) <br /> a r <br /> i EH 14.213 ado f j <br /> r <br />