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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O O <br /> (Complete in Triplicate) <br /> herein <br /> . This applcation is <br /> Application is hereby made tSan County O d nalncle No 549 for sewage orpermitealth District for a construct <br /> 1862 forwell//pump and the R l s and Regulations of the Sanl Joaquin <br /> made in compliance with Sao Joaquin <br /> Local Health District. r 1 <br /> Lot Size <br /> PM <br /> Si <br /> City n <br /> Job Address hj <br /> Phone i <br /> Add4iAo" <br /> . <br /> Owner's Name Contractus Phone <br /> N W WELL ❑ ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER LJ•- P_UMP INSTALLATION ❑ FLD. PROP. LINE <br /> SEWER LINES DISPOSAL <br /> l DISTANCE TO NEAREST: SEPTICTA�NK,. OTHER WELL PITS/SUMPS <br /> FOUNDATION �'A" G_RICULTURE WELL <br /> INTENDED-USE ^--TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L1-Open„Bottom ❑ Manteca Dia. of well excavation <br /> ❑ Industrial �"� _ Specifications ` e <br /> -...,❑ Trac 'Type of Casing =t \`Il <br /> ❑ Domestic I Private Cl Gravel Pack Y r✓�r, '”--Type of Grout — <br /> F1 Other Ci Delta-----,Depth of Grout Seal F <br /> I1 PublicSurf6ce-Seal_Installed by <br /> ! I Irrigation Approx. Depth I I Eastern Do+ `---- <br /> H.P. <br /> —State Work nee <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Filler Material (Below 501 <br /> Depth <br /> N l I DESTRUCTION I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITIOI availablelwthin red if public sewer_is <br /> 200 feet.) » <br /> tnstallation will serve: Residence Commercial <br /> Other <br /> Number of living units: -4— Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg III <br /> Method of Disposal <br /> PKG. TREATMENT PLT. d OProperty Line*Of <br /> Distance to nearest: We11 _� Foundation <br /> l r Cl r .�.�. Total,lengthlsize x <br /> LEACHING LINE a Noh Length of lines i propertyLine-- — <br /> y O Distance to'earest <br /> Well Foundation�L,L_ItL <br /> FILTER BED '1 <br /> Number <br /> SEEPAGE PUTS l If]epth 111a ` Property Line <br /> Mp ❑ Distance to nearest: Well 1-�(� undation r <br /> jq I t <br /> ISPOSAL 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 o California.'"Contra eosonhiring <br /> irrto ookman1scompensa- <br /> i certifies the following;"i that in the performance of the work for which this permsignature <br /> it is issued, I shall employ psubject <br /> 4 tion laws of California" e <br /> The applicant must c r all i quired i pe tions. Complete wing on reverse side. <br /> _ Title: Date: <br /> Signed X <br /> I FOR EPARTMENT USE ONLY <br /> Date r Area <br /> Appli tion Accepted by <br /> Dat �# F�inall ection by. �Tri/`/,ci( �� lei Date�L <br /> 1 t or rout Inspection by IF <br /> l <br /> Additional Comments: <br /> ❑ Stk 466-6781 D 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 /> C CK RECEIVED BY DATE PERMITENO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> �p :Z-S� <br /> l +.EH 13-24 IREV.185) <br /> EH 14.28 <br /> I <br />