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APPLICATION FOR PERMIT <br /> # SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> -= PERMIT EXPIRES 1 YEAR FROM DATE ISSUED''s "� <br /> y � (Complete in Tripllcate) <br /> Application is hereby made to the SaCounty ui Ordinal ce No.District <br /> for f r age or INo. 1862 for well/pump and the Ryles cation is <br /> and IR Regulations of the San Joaquin <br /> made in compliance with San Joaquin _ <br /> Local Health District. t <br /> A of Size <br /> y City <br /> Job Address f " <br /> Phone <br /> Address- s/ <br /> Owner's Name ;-. T,- t �' !` - <br /> ,fPhon <br /> ! License No. <br /> Cantrac - 1` <br /> Address. - <br /> 'i NEW WELL❑ WELL R ACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL PUMP: '^ SYSTEM REPAIR ❑ OTHER E3PUMP INSTALLATION ❑ °s'` . . DISPOSAL FLD. PROP. LINE <br /> � S T% SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: <br /> SEPTIC TANK t AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> INTENDED USE TYPE OF WELL I PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> I ❑ Industrial ❑ Open Bottom ❑PManteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> LD Domestic/ Tracy pomesticlPrivate ❑ Gravel Pack Depth of Grout Seal Type of Grout {� <br /> ` <br /> El Public El Other ❑ Delta <br /> ❑ Irrigation ,-4pprox.,Depth� Eastern <br /> Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump^' I . H.P. <br /> State Work Done <br /> �1`,-Sealing Material atop 50'1 <br /> Well Destruction ❑ Well Diameter +µ Filler Material (Below 50') <br /> Depth <br /> TYPE OF S7 PTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DESTRUCTION LJavailablelwithin system <br /> 200 fitted if public sewer is <br /> eet <br /> � t <br /> Installation will serve: Residence Commercial—, Other <br /> Y <br /> Number of living units: Number of bedrooms kWater table depth <br /> Character of soil to a depth of 3 feet; No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> $ Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Pro a Line <br /> Distance to nearest: Well Foundation p rtY <br /> LEACHING LINE El ­No. &-Length of lines '^--Total-lengthlsize- <br /> ., <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth ' Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> nsignature <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contracts ons�ring or subject to workmanlscompensa <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe <br /> s tion laws of California." <br /> The applicant call for all squired spections. Complete drawing on rev se side. <br /> 44a Title: ��"`� Date: <br /> Signe - - �- --.,..s+.--.^--,�.,.-.-,r..�-. <br /> ..-..rte-,.�..�., �,,.,.�•.,.,.� <br /> FOR DEA TMENT USE ONLY �7 Date <br /> '2 �� Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final Inspection b Date <br /> F9% <br /> Additional Comments: <br /> ❑ Stk 466-6781 odi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all pies Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK# RECEIVED BY DATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED <br /> INFO , <br /> + EH 13-241REV.1/857 -s <br /> EH 14-26 _ ,, „ <br />