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APPLICATION FOR PERMIT J T <br /> .. - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YtEAR FROM DATE ISSUED / <br /> (Complete in Triplicate) 13n., e� ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is <br /> or No. 1862 far welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> 4a City Lot Size PM <br /> Job Address <br /> i <br /> Address . __ Pho —a7560,3 <br /> l <br /> Owner's <br /> . Na 4�� <br /> � Ayet�//� u v <br /> Addre Pho e— <br /> - License N . <br /> Contract , <br /> TYPE OF WELL/-PUMP:., NEW WELL ❑ _ WELL REPLACEMENT,Q DESTRUCTION ❑ _ <br /> PUMP_INSTALLATION ❑ SYSTEM REPAIR ❑ THEA ❑ <br /> DISTANCE TO NEAREST i SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT LL . OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROSL EA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial El Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> Specifications <br /> ❑ Domestic I Private ❑ Gravel Pa 0 Tracy Type of Casing i <br /> 171 Delja Depth of Grout Seal Type of Grout — <br /> FI I Public s i <br /> I I Irngation ___Approx. Depth i I Eastern Surface Seal Installed by <br /> Rep r Done Type of Pump H:P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material itopry50'f, <br /> Depth Fill—'Material (Below 501' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR lADDITION11—DESTRUCTIO INo septic system permitted if public sewer is } <br /> i available within 200 feet.i t <br /> i <br /> Installation will serve:' Residence— Commercial Other r Y <br /> Number of living units: = Number of bedrooms <br /> Character of:soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK * C1 Type/Mfg F Capacity-----!—F No. Compartments <br /> PKG. TREATMENT PLT. 1-1t " Method of Disposal <br /> II "" Distance to nearest: Well Foundation Property.Line . <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ElDistance to nearest: Well 'Foundation Property Line <br /> SEEPAGE PITS { I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑. <br /> hereby certify that I have prepared this application and that the work will be done in accordance with SanJoaquin 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: "f certify'fhat 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." �'f <br /> The applica ust call for all required inspections. Complete drawing on reverse side. <br /> Sig Title: Date: <br /> FOR DEPARTMENT USE ONLY - <br /> " Date _ Area <br /> Application Accepted by al Q <br /> Ins <br /> Pit at Grout Inspection by .Date <br /> Final Inspection by oat. <br /> Additional Comments: <br /> l ❑ Stk 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, Silk., CA 95201 <br /> 3 - <br /> x FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> INFOale <br /> 7 <br /> ♦ EH 13-24(REV.t/n 5) � <br /> -EEH 14-28 <br />