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,;• ,;e A KICATION FOR PERMIT <br /> SAN JONQUIN LOCAL HEALTH DISTRICT N <br /> 1601 E.- HAZELTON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) i <br /> Application is hereby madeJoa n County Ordinalncle No.549 for sewage or ealth.District for a Permit <br /> No- 1862 for welupump and the work herein <br /> and Regulations of he San l Joaquin <br /> t <br /> made in compliance with Sann qu <br /> Local Health District. ` <br /> City "A) Lot Size 0-7.1Z' <br /> X! O v PM <br /> Job Address // oc r <br /> .t-0' Or 012 Phone _0 <br /> Owner's <br /> License No. Phone <br /> Name. W" `S Address ` <br /> Contractor <br /> � Address <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ � <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11 <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> F DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE.,WELL,. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> I� ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> 171 Domestic/Private ❑ Gravel Pack -❑ Tracy yp g Type of Grout <br /> k fl Public ❑ Other ❑ Delta Depth of Grout Seal <br />! I i Irrigation —.-Approx. Depth ( I Eastern Surface Seal Installed by <br /> jH P State Work Done <br /> Repair Work Done E3 Type of Pump w <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I ! DESTRUCTION availabperwt in 200 feetc system t.) if public sewer is <br /> I 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 of 3 feet: <br /> C <br /> SEPTIC TANK ❑ Type/Mfg apacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> F , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 ) Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F 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. <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 compensation laws of California." Contractor's 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 /> Thea icant t call for all required inspections. Complete drawing on reverse side. , <br /> Signed f Title: Date: <br /> FOR <br /> DEPARTMENT USE ONLY <br /> r - <br /> k Application Accepted by <br /> Date I Area r <br /> j Pit or Grout lnspecti pate ,Final Inspection by Date <br /> Additional Comments: <br /> El5tk 466-6781 ❑ Lodi`369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CK R RECEI D BY DATE PERMITNO.q <br /> EH 13-24 VIEV.+ N 5) 3—,F7 <br /> EH <br /> EH 14-25 <br />