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APPLICATION�FOR P9RMIT <br /> u SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> V.- `' 1601 E, HAZELTON AVE., STOCKTON, CA MAY 18 1990 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED EN IIPViMs AL HEALTH <br /> (Complete in Triplicate) <br /> work <br /> or install the <br /> Application is hereby madanothe Joaquin County ordinance Local <br /> lNto.549 for sewage or permit <br /> No, 1862 forconstruct <br /> well pump and the Rules and VICES <br /> (Regulations of Thisapplication <br /> San Joaquin <br /> made in compliance with S <br /> t <br /> Local Health District. f <br /> ® L6 � �-Ct7rSize PM <br /> City <br /> Job Address <br /> _ Phone J <br /> Address <br /> Owner's Name s <br /> Contractor Address <br /> License No��Q—phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑4�� DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR � OTHER ❑ <br /> PUMP INSTALLATION 12 < <br /> SEWER LINES _ DISPOSAL DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation r <br /> ❑ Industrial Specifications <br /> li Type of Casing � <br /> Domestic/Private ❑ Gravel Pack d Tracy Depth of Grout Seal Type of Grout <br /> hl Public r Other Cl Delta _ <br /> f I Irrigation —APProx. Depth l I Eastern ace Seal Installed by le <br /> H.P, <br /> State Work Done <br /> Repair Work Done t{LT Type of Pump <br /> �_ Sealing Material (tp'50'1 r"s <br /> Well Destruction D r Welk Diameter Filler Material (Below 50') y <br /> a ` 'Depth (74 <br /> TYPE OF SEPTIC WORK: NEVNI,INSTALLATION t 1 REPAIRlADOITION 1.1 DESTRUCTION I I (No septic SYSc Shin 200 feetit'ed i( public sewer is <br /> G <br /> f Installation will serve: Residence, Commercial— Other — <br /> Number of living units: "Number of bedrooms -� <br /> �:�<�•4 Water table depth <br /> Character of soil to a depth of 3 feet: �-- <br /> Capacity No: Compartments hn <br /> SEPTIC TANK Ll Type/Mfg t `( {� <br /> MAhod of Disposal <br /> PKG. TREATMENT PLT. ❑ property Cine <br /> Distance to nearest: Well Foundation <br /> i Total,length/size <br /> - <br /> LEACHING LINE ❑ No. & Length of lines pro ert Line <br /> i FILTER SED ❑ Distance to nearest: Well Foundation P Y <br /> SEEPAGE PITS I I Depth Size _ Number <br /> F Pro ert Line <br /> SUMPS L1 Distance to nearest: Well Foundation P Y <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 /> r employ any person in such manner as to became 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.cos k for which this permit is•issued, l shall employ persons subject to workman's compen <br /> 1, tion laws of California." <br /> The applicant mu call for all required -ins ction Complete drawing on reverse side. <br /> Date: <br /> I Title: <br /> Signed X <br /> / F DEPARTMENT USE ONLY <br /> Date Area <C <br /> Application Accepted by <br /> rFinal Inspection by <br /> Date <br /> Pit or Grout Inspection by Date ._.___..- <br /> I Additional Comments: <br /> El Stk 466-6781 Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy (335-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave,, P.O. Box 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> ..EH13-241REV.i/x515 <br /> EH 14-26 <br />