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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �}QW� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> rribe <br /> . This <br /> cation is <br /> Application is lance withdSanoJoaqu n County ordinance Local <br /> NHealth <br /> o.549 for sewage or permit <br /> No. 1862 foconstruct <br /> welUpump and the Rules and herein <br /> Regulations of the San Joaquin <br /> made in compliance <br /> Local Health District, <br /> Vii" Lot Site PM <br /> Job Address w ty0y Ph l�4Y d <br /> Owner's Name Address p/ <br /> Address `L Liicens <br /> r4 PhdFte �aJ <br /> Contfacto <br /> TYPE ELL/PUMP: NEW WELL ❑ �. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FL-O. PROP, LINE <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES <br /> _ FOUNDATION AGRICULTURE WELL OTHER WELL — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO CATIONS pia. of Well Casing <br /> ❑ Industrial L3 Open Bottom ❑ Manteca Dia ell Excavation <br /> Specifications <br /> ❑ Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing Type of Grout L <br /> {`1 public F1 Other elta: Depth of Grout Seal yp v <br />` tern Surface Seal Installed by <br /> I I irrigation epth t ] Eas <br /> e of Pump H.P. State.Work Done— <br /> Repair Work Done yp j <br /> Sealing Material (to 50'1 <br /> Well Des n L3 Well Diameter Sea r g p <br /> Depth Filler Material'-(Below 50'i <br /> perm <br /> WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCT( INo septic m 1e itted if public sewer is <br /> TYPE OF SEPTIC vailable within <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms =,r Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Type/Mfg - Capacity Na. Compartments ZL3SEPTIC TANK - - '"' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation _Property.Line A <br /> LEACHING LINE L1 No. & Length of lines • Total length/size x <br /> R <br /> FILTER BED D Distance to nearest: Well -Foundation r Property Line <br /> SEEPAGE PITS I1 Depth Size w Number <br /> {' SUMPS Cl Distance to nearest: . Well Foundation Property Line <br /> i <br /> DISPOSAL PONDS ❑ <br /> 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,l shall employ persons subject to workman's compensa <br /> r <br /> i tion laws of California." ,vs� . . - w.�- � -• <br /> f{ The applicant st call for all require s ciions. Complete drawing on�rarsoside. A � <br /> e: Date: <br /> Signe Titl <br /> v l ,; { <br /> r ' �'F DEPARTMENT USE ONLY <br /> Date Area t <br /> Application Accepted by �..` <br /> I Pit or Grout inspection by Date Final Inspection by <br /> . �..��- Date <br /> M � / <br /> Additional Comments: <br /> ElStk 466-6781 (71 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 �K RECEIVED BY DATE PERMIT'NO. <br /> INFO AMCOUN�T DUE AMOUNT REMITTED CA5H <br /> r.EH 13-24(REV.I/A5) <br /> EH 14-26 ✓ <br />