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+ . APPLICATION FOR PERMIT <br /> ° . <br /> Kit <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEARTROM DATE ISSUED <br /> (Complete in Triplicate) _ <br /> is <br /> ri .This <br /> Application is hereby made toJoaquin the <br /> San <br /> Co Joaquin <br /> Ordinance No.D5 istrict <br /> for sewage or permit <br /> 1,362 forcwall/pump anheroin <br /> Local Health ford the Rules and Regu�lations of the San Joago u n <br /> Inty <br /> made in compliance with <br /> Local Health District.'Lill,7 <br /> City Lot Size <br /> Job Address <br /> Phone <br /> ; a <br /> Owner's Address Name <br /> Contractor Address <br /> f License No. Pfiane <br /> NEW WELL ❑ WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELL/ U P: SYSTEM REPAIR [I OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES �� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> ' FQUIVDATiON _�� <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom L1 Manteca Dia. of Well Excavation <br /> ❑ industrial Type of Casing Specifications <br /> Domestic/Private C3 Gravel Pack C3 Tracy Depth of Grout Seal <br /> Type of Grout <br /> ❑ Public ❑ Other ' ❑ Delta <br />` �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> L] Irrigation State Work Done G <br /> H"P. <br /> Repair Work Done ❑ Type of-16 Pump Sealing Material {top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material (Belo <br /> Depth <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if pu is sewer+s <br /> t S I <br /> k Installation will serve: Residence� Commercial�� Other <br /> Number of living units: Number of bedrooms Water table depth <br /> S ' <br /> f Character of soil to a depth of 3 feet: Capacity i� No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Deposal <br /> t <br /> :PKG. TREATMENT PLT. ❑ s r lb } <br /> , _� ' �n Property Line <br /> Distance to nearest: We� # <br /> Total lenL7Lne <br /> LEACHING LINE ❑ 'No. & Length of lines Foundation PFILTER BED ❑ Distance to nearest: We11� r,l}` Depth Siie - NumberSEEPAGE PITS 'Foundation SUMPS ❑ : Distance to nearest: W611 <br /> DISPOSAL PONDS i ❑-' _ "-l hereby certify that 1 have prepared this applicatian and that the work will be done in accordance with San rdinances, state Iaws,''a#d <br /> rules and regulations of the San Joaquin Local Health District. 1' <br /> Homeowner or licensed agent's signature certifies the following:��1 certify that in the performance of the.work for which this permit is issued, I signature <br /> shall not <br /> of <br /> employ any person in-such manner <br /> an Lha tin to become the performance the work for which this compensationlaws <br /> is iss edrfI sfiaN employ pe�sonslsubject t ring or workman'sgompensa <br /> certifies the following certify / <br /> tion laws of California." <br /> The applicant must call for all re utre inspections. Co ete drawing on reverse side. Date: <br /> Title: <br /> ' Signed <br /> �. FOR DEPARTMENT USE ONLY <br /> F Date Ar a <br /> Application Accepted byu � N <br /> ���Dte <br /> Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: 1 ❑ Tracy 835-6385 <br /> ElStk 466-6781 ❑ Lodi 369-3621/ <br /> [I Manteca 823-71 Stli CA 95201 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK RECEIVED BY DATE PERMIT`N0. <br /> FEE MOUNT DUE AMOUNT REMITTED CASH <br /> INF 2 �2� <br /> +EH 13-24 IREV.5/a 5) c.-1 <br /> EH 14-28 <br />