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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT P1?-/0P TMJ ?, <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> I Telephone 52091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM ©ATE ISSUED <br /> {Complete in Triplicate) <br /> . This application is <br /> /or install the work <br /> iuin Local Health District for a per <br /> Application is hereby made to the San <br /> CounJozgty Ordinance No.549 for sewage or INo. 1862 forcwellaherein <br /> pump and the Rules andR Regulations of the San Joaquin <br /> made in compliance with San Joaquin <br /> Local Health District. <br /> 7-s <br /> City S T7ca/ Lot Size S X 3 PM <br /> Job Address 2 ,r� %.I S <br /> I <br /> _ f S' ,D'GK.r'^�1 Phone <br /> Address I <br /> Owner's Name L G <br /> L. � / 32'7 <br /> Contractor *� �Address '7 i1 A l7e�� �= r <br /> License No. Phone <br /> WELL REPLACEMENT LJ DESTRUCTION El <br /> TYPE OF WELL/PUMP: NEWLL=❑-WEOTHER ❑ <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES �� DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK .� -- OTHER WELL PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Traby Type of Casing <br /> j ❑ Domestic/Private ❑ Gravel Pack - Depth of Grout Seal Type of Grout <br />`I Ll Other F! Delta <br /> ['I Public Surface Seal Installed by <br /> t I Irrigation �.Approx.'Depth l I Eastern r HState Work Done — <br /> IP <br /> Repair Work Done ❑ Type of Pump <br /> N <br /> "Sealing Material (top 50'i <br /> Well Destruction ❑ Weil Diameter �- _. _ <br /> Depth I Filler`Material [Below 50'! <br /> TYPE OF SEPTIC WORK-' NEW INST{ELATION I:I REPAIRIADDITION QFSTRUCTION I I alvailableseptic <br /> wi hin 200 feettled if public <br /> sewer is <br /> t Installation will serve: Residence Commercial Other� <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet.. - Capacit No. Compartments <br /> SEPTIC TANK <br /> El l c T/ Y <br /> �''•Method of Disposal <br /> E PKG. TREATMENT PLT. ❑ "4 "Foundation Property Line <br /> Distance to nearest: WelI ,.,. <br /> -/ =,. �� Total length/size _ <br /> LEACHING LINE I Dr <br /> No. & Length-of-lines '� Property Line <br /> D Faundation P y <br /> FILTER BED,,h ❑ Disiance to nearest: Well <br /> I I Depth Ir �(�'� Size —�. 17- Number z <br /> SEEPAGE PITS <br /> SUMPS 1 Z.f' Property Lined <br /> Distance to nearest: Well I fid Foundation - <br /> � , <br /> ` DISPOSAL PONDS ❑ 1 <br /> 1 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. work for <br /> Homed owner or <br /> licensed <br /> agent's manna as torbecome subject e certifies the Ito w1orkman's coympansation lthat in the aws of California."Contractor'srhiri g'or sub-contracting)signatushall re <br /> employ y p ersons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> l .t-. !ii/ Title: Date: <br /> i Signed X.. <br /> FOR DEPARTMENT USE ONLY <br /> k } Data /��— Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Data <br /> Final Inspectin by Data <br /> t <br /> I Additional Comments: <br /> ❑ Stk 466-6781 13 Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 <br /> P.O. tk., CA 95201 <br /> Applicant Return all copies to: Environmental Health Permit/ .1601 E. Hazelton Ave., P . Box 2009, <br /> --=tet- -� _'.� <br /> C RECEIVED BY DATE PERMIT'NO. <br /> r FEE AMOUNT DUE AMOUNT REMITTED H <br /> INFO 11L <br /> i O f�D <br /> ♦.EH 132 (REV.1/H 5) <br /> EH 14-28 <br />