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l✓ { "� 4 �= APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> tAk Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ed.This appIkAr&M is <br /> Application is hereby made to,oa u nSan <br /> 'County Ord Hance No.549 for sewage of-Na 1862 forconstruct <br /> wellIpump ainstall <br /> nd the Rules and'Reg lu atio of the San Joaqu n i <br /> made in compliance with San q :;1 h <br /> Local Health District. <br /> } p 1 <br /> City Lot Size <br /> Job Address 7 a <br /> Owner's Name <br /> Address u ry Phone <br /> Address License No. Pfione <br /> Contractor <br /> i - <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> _——DISTANCE TO-NEAREST:-SEPTIC>TANKg*SEW•ER-L-INES_ - —-<–DISPOSAL–FLD:--�-! - . <br /> ' FtOP-.-LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS LW <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA,,C-6NSTRUCTION SPECIFICATIONS s i <br /> ❑ Industrial Open Bottom ,` •�pMnteca �„rOi� f Well Excavation <br /> Dia. of Well Casing <br /> l t` + ►r �r rc Typed using r���°.�..' Specifications g x <br /> 'Dofm� estic/Private ❑ Gravel Pack +`TAY ? r ! T of Grout ,C <br /> ❑ Pubic ❑ Other ❑ Delta Depth of Grout Sealt, I - P� <br /> i rax. Depth ❑ Eas rn ' '�'Suhaoe Seal Installed by <br /> t <br /> B Irrigation app - t r'_1i i <br /> H p. -1`° State Work Done <br /> Repair Work Done ❑ Type of Pump _ � <br /> l <br /> + �'. aling Mae�ial top '1 r ` <br /> well destruction LlWell Diameter ( 50 _� �.� <br /> Depth Fi1f`er�Material�{Below`a1 <br /> TYPE1OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/A�fDOITIO� DESTRUCTION ❑ (No sbpekwth syavastem <br /> permitted'rf public sewer is <br /> Installation will serve: Residence— Commercial, Ot a <br /> 4 i <br /> Nurilber of living units: Number of bedrooms `IANater table depth ` <br /> Character of soil to a depth of 3 feet: <br /> f apacity "� �No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> """" Vleihod o disposal <br /> PKG. TREATMENT PLT. ❑ _ i <br /> '4.. `'Distance to nearest: Well Foundation <br /> ] ' Property Line .— <br /> =R: <br /> + 1 Total,length/size i <br /> LEACHING LINE i Q Na. & Length'of lines *_q g s <br /> FILTER BED ❑ <br /> Distance to nearestr ' Well � PFoundation rope 4 Line <br /> SEEPAGE PITS ❑ Depth —Size Number ' <br /> i_.•., ...,, <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin bounty 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 /> 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 perso6s subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t all for all required inspectioae. Complete drawing on reverse side. <br /> Signe Title: ] rT Date: <br /> r FO EP�iRTMENT USE ONLY <br /> QS <br /> Date L4-ZI3-� Area <br /> Application Accepted by ; <br /> Date-S� Final Inspection by Date _ <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ 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 /> FEE CK RECEIVED BY DATE PERMIT'NO." <br /> AMOUNT DUE AMOUNT REMITTED CASH tett ^.{y1 1t !r�'�11 <br /> + EH 13-24 iREv.1/s 51 INFO �O, UO <br /> EH 14-28 <br />