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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E..HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; <br /> (Complete in Triplicate) <br /> ica*m is <br /> Application is hereby made to the Joaquin County ordinance lHealth No.District49 for sewage or No.1862 forcwell and/orinstall <br /> and he Rules and Regu�lati�of the Sa.This wn Joaquin <br /> made in compliance with San tY <br /> Local Health District. .. <br /> Job Address <br /> 4 City $ Tao Lot Size PM <br /> i) 1 Sac <br /> Owner's Name S ress Phone,� Add <br /> Contractor Address 7 N ��r )'+ License No. 4-3 q-7/1 Phone <br /> TYPE OF WELL/PUMP-, . '; , NEW WELL' F1WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLOION ❑ ,. SYSTEM REPAIR ❑ OTHER i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. '?ROP'. LINE <br /> FOUNDATION .AGRICULTURE WELL OTHERWELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial tp-Open Bottom -"—❑ Manteca-----`----Dia: of-Well-Excavation�' <br /> Specifications <br /> n Domestic/Private Cl Type of Casing Gravel Pack ❑ Tracy T of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type <br /> ❑ Irrigation — Approx".-Depth—O Eastern------Surface-Seal-Installed"S to Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Wellh Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ;. REPAIRIADDITION ❑ :DESTRUCTi aifabpeiwitsystem <br /> ne200 feet�ied if public sewer is <br /> Installation will serve: Residence_ Commercial. ;Other--� " ' <br /> Number of living units: Number of bedrooms { <br /> Water table depth <br /> Character of soil to a depth bf 3-feet No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> -- Method of Disposal <br /> PKG. TREATMENT PLT. Ll <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> q Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED 1-1Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> i <br /> Property Line <br /> SUMPS <br /> 1-1Distanceto nearest: <br /> ,Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 4 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 /> ' 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, 1 shall not <br /> i employ any person in such manner as to become subject to workman''s compensation laws of California."Contractors hiring or sub contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed r <br /> c r— a.r ""atl P <br /> Title: Date: <br /> - <br /> FOR DEPARTMENT USE ONLY05- <br /> _ Area <br /> Date <br /> -�� Application Accepted by <br /> Pit or Grout Inspection by Date 4 Final lnspectiori Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 C3 Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 EE.Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE K RECEIVED BY DATE PERMIT'NO." <br /> )NFO AMOUNT DUE AMOUNT REMITTED <br /> 1�i� b��to7 <br /> + EH 13.24 1REV.1/e 57 S �p <br /> EH 14-28 W <br />