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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 /> plication is <br /> Application s heiebyk ante wimadth SanoJoaqu n County ordinance the San Joaquin llNto.549 for sewage or permith District for a to <br /> for cwell/dpump and the Rules and hereinall the work R Regula <br /> of the San Joaquin <br /> made in co p _ ��,(� <br /> Local Health District. PM <br /> �-{ <br /> � City L: Lot Size I <br /> ` Job Address G. <br /> Address SIL,r- Phone <br /> Owner's Name <br /> Contractor� Address .rte - <br /> icense No E Phone2 <br /> TYPE OF WELL/PUMP: NEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION El <br />�. PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR LlOTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES _ DISPOSAL FLO. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION i <br /> INTENDED US TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Casing <br /> f Type of Casing Specifications <br /> �(jomestic!Private ❑ Gravel Pack ❑ Tracy Delta Type of Grout – <br /> - <br /> Depth of Grout Seal <br /> f"7 Public 11 Other F1 ' <br /> I I irrigation .-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump <br /> H.P. <br /> State Work Done <br /> ? Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> Zrm` °TYPE OF SEPTlC,1NORK: NEW INSTALLATION' <br /> REPAIR/ADDITION ! I DESTRUCTION i I (No septic system <br /> t 200 feet if public sewer is <br /> l Installation will serve: _-4—Resigdence� Commercial— Other i + <br /> Number of living units: Number of bedrooms <br /> i - Water table depth <br /> Character of soil to a depth of 3 feet: r No. Compartments <br /> SEPTIC TANK Type/Mfg Capacity — i <br /> Method of Disposal 1 <br /> PKG. TREATMENT PLT. D <br /> Distance to nearest: Well Foundation Property Line <br /> .5 r r Total lengthlsize <br /> i LEACHING LINE No. & Length of lines 00 1'1 <br /> t <br /> FILTER BED ❑ Distance to nearest: ell Foundation �� Property Line�� , <br /> Number <br /> r SEEPAGE PITS I 1 Depth Size <br /> d Distance'to nearest V17eII 7 �� 'Foundation y O r Property Line a <br /> DISPOSAL PONDS ❑ <br /> Thereby 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 /> Id <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 /> ` of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws ' <br /> t : "I certify that in the performance of the work for whi�h-this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the following <br /> tion laws of California." <br /> The applicant r%isti,call for all required inspections. Complete drawing.on revefse side. <br /> J Date: <br /> Signed X j Title: <br /> FOR DEPARTMENT USE ONLY ` <br /> r 7 j <br /> ( Date Area <br /> I pplication Accepted by <br /> Date �����iinalC_Inspection byDatrG utTnspection by <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑.Lodi 369 3621 ❑ Manteca 823x71043; ❑ Tracy 835-6385 <br /> I 5tk., CA 85201. <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601_E..Hazeiton Ave?, P.O. Box 2009, <br /> FCK RECEIVED 6Y�- DATE PERMIT'NO. <br /> EE - <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> +.EH13-2�41REV.irns� ��Dr10 �.�7I <br /> t EH 14-26 <br /> t - <br />