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Vyv Tr � T . <br /> *' APPLICATION FOR PERMIT ��� <br /> AL HEALTH DISTRICT l , <br /> SAN JOAQUIN LOC <br /> S+, <br /> 1601 E. HAiflL t 01V AVE., STOCKTON, CA 7 <br /> Telephone (209) 466-6781 , <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED �.NVIRO %AE iTAL HEALTH <br /> I <br /> (Complete in Triplicate) -f R.�1��[zTTita'V�GICatlon is <br /> Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct ell <br /> install the work herein esarl <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well!pump and the Rules and Reg 1 <br /> A <br /> Local Health District, PM <br /> of Size <br /> Job Address v <br /> 1 Phone I <br /> Owner's Name // <br /> 1 <br /> License No. �J Z3 U Phone <br /> Contractor WELLREPLACEMENT ❑ DESTRUCTION ❑ '` <br /> NFW W LL ❑ OTHER ❑ <br /> TYPE OF WELLIPUMP,: SYSTEM REPAIR ❑ �' <br /> 1Z <br /> "'�Z - PUMP INSTALLATION ❑.. DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAs <br /> '' �`- =� �-� SEWER LINES �---- <br /> REST: SEPTIC TANK �� AGRICULTURE WELL OTHER WELL PITSISUMPSf.a ( An <br /> c FOUNDATION — =� t <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f <br /> INTENDED USE Dia. of Well Casing <br /> p Open Bottom L.D.Manteca Dia. of Well Excavation y <br /> ❑ Industrial I �`� Specifications <br /> :., <br /> QTracy Type of.Casing <br /> OD Private„ id Gravel Pack. w Type of Grout <br /> s`. °❑ Other ,❑"Delta Depth of Grout Seal t <br /> (`l Public /f Su ace Seal Installed by <br /> 11 Irrigation <br /> Approx. Depth 1, astern r <br /> : r .P., State Work Done_ <br /> Repair Work. Done l I YPa of Pump fi r- r <br /> Sealing Material (top 50'1 <br /> Well Destruction Q Well Diameter ; <br /> I✓"' " ' De th I w`Filler Material (Below 50'1 <br /> ` <br /> w p <br /> TYPE,OF SEPTIC WORK: NEW INSTALLATION I:1 'FiEPAIR!'ADDITION i I QESTRUCTION i I aNailabpelwi hine200 teat.) if public sewer Is <br /> Ins�ation will serve: Residence— <br /> Commercial— Other <br /> ` <br /> Number of living units: Number of bedrooms Water table depth <br /> Cha(acter of soil to a depth of-3 feet: Capacity No. Compartments <br /> SEPTIC TANK p Type/Mfg Method of Disposal <br /> 1 PKG. EATMENT PLT.❑ Js` <br /> i Foundation Property Line <br /> Distance to nearest: Well F, <br /> .r Total le6gth/size <br /> LEACHING+LINE Cl No. &Length of lines Property Line f <br /> 1 FILT ROBED <br /> ❑ Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS I I Depth Property Line <br /> SUMPS <br /> f Cl Distance to nearest: Well Foundation # <br /> , - <br /> DISPOSAL PONDS ❑ t - <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances'r state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or Ii nt's signature certifies the following:"I certify that in the performance of the work for which this permit is issued, I signature <br /> she not <br /> employ any p an in such rine as to become subject to workman's compensation laws of California."Contraceon$Isubjectring rto workman's9ompensa <br /> certifies the ollowing: '"l ce y that in the rforma of the work for which this permit is issued,I shall employ pA <br /> tion laws f Calilornia." <br /> The ap Icani,must c all re s. Co drawing on r si <br /> Date: <br /> ik Title: <br /> Signed <br /> --,--FOR]R PARTMENT USE ONLY <br /> Date ` f Area <br /> Application Accepted by r' ' <br /> Y h Final Inspection by.� ��'�'� Date <br /> Pit or Grout Inspection by Date e <br /> Additional Comments: <br /> ❑ Stk 466-6781 fl Lodi 369-3621 ❑ Manteca 623-71f?A ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Elvironmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F CK PERMIT NO. <br /> ffjV CASH RECEIVED BY DATE <br /> AMOUNTE AMOUNT REMITTED <br /> r <br /> I` J <br /> EH14-26 <br />