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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. H ZELTON AVE.,•STOCKTON,CA <br /> Telephone (209) 466-6781 .. .. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / Y•i64A­ccx-Lo <br /> ;•,,.(Complete,in Triplicate) appt <br /> k herein <br /> wcT <br /> Application is rn )lance with San�Joaquthe an County Ordinance n Joaquin l �No.S49 for sewage or{Vo 1862 for wellth District for a permit to construct nl/dpump install <br /> nd the Ru eI s and Regulatiion is <br /> ons of the San l Joaquin <br /> made in P C a <br /> Local Health District. t rt, ,) LK' • !! , <br /> ,. " fat <br /> 1PM <br /> t1 City Lot Size_ <br /> Job Address ¢¢'�� <br /> � A . . <br /> =' ':y t w,.Pis 'C' Address Phone <br /> Owner's Name __... r <br /> �� F(.. ress AddLicense No. Phone <br /> Contractor <br /> ! TYPE OF WELL/PUMP:l NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ .�. <br /> .PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t 0 <br /> _ SEWER LINES DISPOSAL FLD. PROP. LINE t,1 <br /> DISTANCE TO NEAREST: SEPTIC TANK - PITS/SUMPS t" <br /> FOUNDATIONS ' 4bRICULTURE WELL OTHER WELL i <br /> INTENDED USE i 'GYBE OF WELL\ }PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> El industrial C Open Bottom O_M_anteca.,. Dia.of yell.ExcaSation_---- : Specifications <br /> f�. T of�Casing Jis .❑ Domestic/Private ❑Gravel Pack ❑ Tracy YPe Type of Grout❑ Public r � ❑ Other ❑ Delta Depth ofG`rout Seal <br /> ❑ Irrigation --Approx. Depth ❑ Eastern ..c�Su-1 -"4eal�lnstalled� t _ State Work Doh6Repair Work Done C Type of Pump _.. H•P Well Destruction ❑ Well Diameter Sealing Material [top 50') e,Depth Filler Material tBelow 50'1 ) ,TYPE OF SEPTICWORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION eN8ila6pe within 200 feetl��f publicInstallation will seiv : Residence,X` Commercial_� Other <br /> Number of living units:_— Number-of bedrooms�_- <br /> Character of soil to a depth of 3 feet: t# Water table depth <br /> SEPTIC TANK r Z ,Type/Mfg <br /> Capacay lid� No. Compartments <br /> %" Method of Disposal <br /> PKG. TREATMENT PLT.C Is <br /> Distance to nearest:• - Well' Fo_unda_`tion y property Line <br /> r. _7 FT Ilengthlsize y-- r+ <br /> -- t - <br /> LEACHING LINE �: ❑ No. & Length of lines <br /> I FILTER BED [i Distance to nearest: Well/!!nn!!'' Foundation ZjQ"' Property Line <br /> r <br /> J <br /> ` SEEPAGE PITS X Depth _24 Size �f �!_�y "� /N ber - <br /> l / �C nrwrty Line <br /> SUMPS f ❑ Distance to nearest:• Well/ Foundation+_� •r.- - <br /> i '-e <br /> DISPOSAL PONDS i k ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance`.wrth San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Local Health District. r u• <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 person in such manner as to become subject to workman's-comaerisation laws issued,Caiif I hall employ" <br /> montractorr's h subject to workmansignature <br /> I certifies the following-"I¢errlfy that in the performance of the work for which tKis pe <br /> rmit is tion laws of California <br /> The applicant must call for all required in tions. C mplete drawing on reverse side. '2—i r- <br /> ' =, <br /> Signed X—._: la <br /> _ Title: Date: --- <br /> FOR DEPARTMENT USE ONLY r <br /> Date <br /> Application Accepted by <br /> Pit or Grout Inspection by r Date Final Inspection by <br /> divonai Comm .ents: <br /> S, 466-781 ❑ Lodi 368-3E21 ❑ Manteca 823-7104 G Tracy 835-6385Ave.,., p. <br /> O. Bax 2009. Stk., CA 95201 <br /> A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton <br /> FEE AMOUNT DUE AMOUNT REMITTED 'r RECEIVED BY DATE PERMIT;NO. <br /> INFO - -- •rr- c. C <br /> .EH 13.24(REV.i/.Ft sl' '*j� `'""•. r f: ►;, .. <br /> iA <br /> EH 14-28 <br />