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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 /> application is <br /> Application is hereby made to the San Joaquin Local Health District for a pe or permit to <br /> 1862 for well/Pump and the R/or install the les andrk construe 'Regulations of Thishhe San Joaquin <br />� made in compliance with San Joaquin County Ordinance No. 549 for sewage <br /> Local Health District. <br /> l (j� City Lot Size PM <br /> Job Address { <br /> Owner's Name <br /> Address U ' ' 'Ahone <br /> Address Uicense No. Phone_ <br /> Contractor i!- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA,T Cl" SYS TE P IR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE_,. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> en Bottom ­C Manteca Ria. Of Well Excavation Dia. of Well Casing <br /> I ��Dostic/ <br /> industrial <br /> P r <br /> Specifications <br /> Private Gravel Pack ❑ TracyType of Casing Typa of Grout -- <br /> ublic Other n Delta Depth of Grout Seal Grout----- <br /> C' <br /> } Irrigation ­Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type Of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ttop 501 <br /> Depth �- -- — =-yFiHer Material (Below 50'1 <br /> F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION - REPAIR/ADDITION t I DESTRUCTION t I (No septic system permitted if public sewer is <br /> l available within 200 feet.) <br /> k Installation will serve: Residence A`- Commercial— Other <br /> Number of lining units: —J— Number of bedrooms <br /> Water table depth <br /> Character of soil to-a depth of 3-feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.'N Method of Disposal <br /> '4:• ? Distance'tq nearest: Well Foundation Property Line <br /> LEACHING LINE P( No. & Length of lines <br /> Total length/size 0 r <br /> FILTER BED ❑• Distance to:nearest: Wekl Foundation Property Line <br /> SEEPAGE PETS Depth Size -3 Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS '❑-� '� <br /> hereby certify that l 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t call for all require inspections. Complete drawing on reverse side. <br /> 5, Signed X i Title: Date: <br /> E411 RTMENT USE ONLY <br /> { A lication Accepted by ' Date Area <br /> ~v <br /> 4W <br /> p' —- -� <br /> Pit or Grout Inspection by 1(,, =L Date Final Inspection by Date <br /> Additional Comments: <br /> lox,/(, sGm z z -7s' hY04 <br /> ❑ 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, Stk., CA 95201 <br /> i FEECK RECEIVED BY DATE PERMIT NO. <br /> IN ^MOUNT DUE AMOUNT REMITTED GJ Vim+/� <br /> f ♦.EH13-241REV.�/K51 / ��� 7U•a'J �����` _�7 f <br /> r. EH 14-26 <br /> I ' <br />