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APPLICATION FOR PERMIT <br /> SAN JOAQUIiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ,. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) sthe work <br /> cation is <br /> /or in <br /> Application is hereby made oaothe San Joauin Joaquin County OrdinatHealth nce No.District549 f r sewage or'No. 1862 fort to cwell/pump t anan the Rules and'R gulations of the San This 1 Joaquin <br /> made in compliance with Sanq <br /> Local_Health District. / <br /> Al City Lot Size,! a7 PM <br /> Job Address <br /> Address Phone <br /> Owner's Name <br /> I} <br /> License No.�,� J�✓A / �- Phone <br /> t Contractor's Name n <br /> WILL REPLACEMENT ElDESTRUCTION LJ <br /> OF WELL/PUMP: NEW WELL F11OTHER ❑ <br /> PUMP INSTALLATION F1 SYSTEM REPAIR ED <br /> ISEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION-,— AGRICUL.TURE WELL- "OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 'Dia. of Well Excavation <br /> - T of Casing Specifications <br /> t�omestic/Private _ ❑ Gravel Pack ❑ Tracy Type g Type of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> t ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done CI <br /> f Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ _Well Diameter _Sealing Material {top 501 <br /> Depth Filler Material !Below 50'1 <br /> * TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADQtTION'❑ DESTRUCTION El (No <br /> -septi Systemithin permitted if public sewA. er is D <br /> Installation will serve: Residence_y_ Commercial., Others <br /> y Number of living units: Number of bedrooms <br /> Water table depth dQ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK >, Type/Mfg �T C�G �tf4Capacity No. Compartments <br /> Method of Dispos5l <br /> i PKG. TREATMENT PLT. ❑ ��� ol <br /> F <br /> Distance to nearest: Well !L = Foundation Property Line <br /> LEACHING LINETotal length/size <br /> ----&K �G_& Length of lines -5 t <br /> FILTER BED ❑ Distance to nearest: Well 1d o Foundation,fy Property Line e— <br /> i <br /> SEEPAGE PITS f Depth r�?.]' Size G Number <br /> SUMPS e to nearest: Well l�U Foundation- 16 'Property Line a <br /> ❑ Distance <br /> DISPOSAL PONDS ❑ <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 /> 4 tify that in the,.performance of the work for which this permit ississued <br /> Home owner or licensed agent's signature certifies the following: "I cer , I shall not <br /> employ any person in such manner as to become subject to workman's compensetiori laws of California." Contractors hiring c so worflmint,g signature <br /> } certifies the following:"I certify that in the performance of the work for-which•this-perH is issued,I shall employ persons subject to workman s compensa- <br /> tion laws of California <br /> The applicant mu for all equired ' spections. Complete drawing on neve71e I <br /> de. F <br /> Signed Title: ate: <br /> E "'. . Cid <br /> FORD ENT USE ONLY . _ 1 <br /> o-. ,...T <br /> Application Accepted by ."t r Date i area <br /> 1 _ .�. <br /> Pit or Grout Inspection by Datet`' Final Inspectldn by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6M <br /> { Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK# <br /> FEE .AMOUNT DUE AMOUNT REMITTED CASH �RECfIVED BY DATE PERMIT'NO. <br /> sINFO �►-*.. _ <br /> + EH 1324(REV.10183) <br /> EH 14428 <br />