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APPLICATION FOR PERMIT a � ,,�1r <br /> � � <br /> SAN JOA LOCAL HEALTH DISTRICT 4 <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA F E 3 2 6 1991 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the <br /> rk <br /> n described.This <br /> cation is <br /> Application is hereby made to the San Joaquinalcle Nto. 549 for sewage permit construct No. iB62 forwell/dpump and the Rues and +Regulations of the San Joaquin <br /> or Joaquin <br /> made in compliance with San Joaquin County Ordinance <br /> Local Health District. <br /> City <br /> Lot Size PM <br /> Job Address r <br /> Phone <br /> Owner's Name Address <br /> Contractor Address <br /> License No. Phone r <br /> NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> TYPE 4e <br /> OF WELL/PUMP: 'PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ <br /> t3 -� <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-- PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> Domestic/Private 0 Gravel Pack racy Type of Grout---. <br /> M Public ❑ Other Ll Delta <br /> Depth of Grout Seal <br /> I I Irrigation _.-Approx. Depth l 1 Eastern Surla e eal stalled by <br /> Repair Work Done 0 Type of Pump H.P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No sePerm <br /> availabptic systec thin m feet-)iF public sewer is <br /> Installation will serve: Residence, Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth {\ <br /> Character of soil to a depth of 3 feet: <br /> Capacity Na. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> "'I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to become subject to workman's compensation taws 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 must call for all squired inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date � Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date 2' <br /> Additional Comments- <br /> El 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 /> EINFO <br /> K RECEEVED BY DATE PERMIT-NO. <br /> AMOUNT DUE AMOUNT REMITTED H <br /> +.EH 13.24(REV. <br /> EH 1d-26 <br />