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APPLICATION FOR PERMIT / <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELsON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Ith <br /> .This <br /> Application is hereby madetothe San Joaquin Joaquin County ordinance No.D549 for for <br /> or permit <br /> No�1862 forcwell/dpump install <br /> nd the ales and Reg tion of the application Joal n <br /> made in compliance with 5 aq y <br /> Local Health District. <br /> 4 ]'��Q a(: 1✓ L.i'r !- City Lot Size PM <br /> Job Address <br /> l T C�, s - Phone <br /> F Owner's Name Address <br /> �; as <br /> 61— <br /> Contractor <br /> Address 5 (_+cense No. <br /> Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE LACEMENT LJ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER <br /> EDISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> a� <br /> t. INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION SPECIFICATI S Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y _ Specifications <br /> 'F Type of Casing <br /> ❑ Domestic/Private LJ Gravel Pack ❑ Delta Depth of Grout Sea! Type of Grout <br /> I <br /> El Public ❑ Other i <br /> ❑ irrigation --Approx. Depth LJEastern Surface Seal Installed by <br /> Repair Work Done L1 Type of Pump <br /> H.P. State Work Done r <br /> fi <br /> Well Destruction , ❑ Well Diameter Sealing Material (top 50'i <br /> Depth Filler Material (Below 50'} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION CJ ❑ DESTRUCTION 13available+wit in 200 eeed if public sewer is <br /> t l <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water=able depth \ <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> al <br /> SEPTIC TANK ❑ Type/Mfg Method of Dispos <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation p rty <br /> Total length/size <br /> k LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ID Distance to nearest: Well Foundation <br /> a <br /> Number <br /> SEEPAGE PITS ❑ Depth Size Property Line <br /> SUMPS EJ Distance to nearest: Well Foundation P rty <br /> A 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: "1 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 /> r which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the following:"I certify that in the performance of the work f <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse sidle. B '; <br /> Signed Title:� �nLocrsT' -- Date: i <br /> F P"T111 <br /> N LY <br /> Date��� Area 9 <br /> Application Accepted by L/ <br /> Pit or Grout Inspec' n b <br /> Date Final Inspection by Date 7''�� <br /> Additional Comm s: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca $23-7104 ❑ c y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box Stk., CA 95201 <br /> 2009, <br /> FEE CK RECEIVED BY DATE PERMIT''NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CA H <br /> EH 14-28 <br />