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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to the San <br /> County <br /> Ordinance llNo.549 for sewage or ealth District for a permit <br /> No. 1862 for well pump end the Rall the tes and rk IR Regulations of tlhe Sanapplication <br /> Joaquin <br /> made in compliance with San Joaquinh' <br /> Local Health district. <br /> _ City Lot Size PM <br /> Job Address <br /> Owner's Name Address Phone <br /> Contractor Address License No.3 O.`i 7. l -Phone�� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> . PUMP INSTALLATION ❑ SYSTEM REPAIR 11 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER W€LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack I] Tracy Type of Casing Specifications <br /> FI Public F] Other r Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION &oobESTRUCTION I;lf INo septic system permitted if public sewer is <br /> available within 200 feet.I <br /> installation will serve: Residence Commercial_ Vthe, <br /> Number of living units: I Number of be rooms OQ! �` <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK R�Type lMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. F7Method of Disposal <br /> Distance to nearest: Well�p ff Foundation D Property Line <br /> LEACHING LINE L1.14o. & Length of lines h1 Total length/size Q <br /> FILTER BED LI to nearest: Well 240— Foundation a u':i~ Property Line / c�l <br /> SEEPAGE PITS ltl'/Depth —4:2 �� _Size Number 2- <br /> SUMPS ❑ Distance to nearest: Well If/0 Foundation to S! Property Line 6 <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 no <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 /> The applicaot must call for aft quir d inspections. Complete drawing on reverse side. �r p <br /> Signed X Title: Date: / 7 <br /> FOR DEPARTMENT USE ONLY }r� <br /> It 10 196 Area <br /> Application Accepted by Date <br /> Pit r Grout Inspection b Date Lc:L C�Final Inspection by Date I 1 o ic, v <br /> Additional Comments: <br /> Q Stk 466-6781 ❑ Lodi 369-3521 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Appllcant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO ` - <br /> +.EH 13-24(REV.i/n s) -U, D "�] Z�� / P O/ O 70400, <br /> EH 1428 L �" <br />