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. - _._ __ . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> . This <br /> made in compliance with Sano the Joaqu nnCounguin Local Health District for a ty ordinance No.549 for sewage or permit <br /> No. 1862 forcwell/pump and the Rules and herein <br /> Regulations of the Sancation is <br /> Joaquin <br /> made in p <br /> Local Health District. <br /> p f` <br /> -! c� ✓r. Lot Size _ PM <br /> City Job Address <br /> Owner's Name � <br /> T11+! Address l l S~`S `S Phone 1-1li6 70 <br /> Contractus S1_1 <br /> Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CCQESTRUGTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ <br /> l <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casio Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy yP g <br /> f l"1 Public 1-1 Other <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> Depth l I Eastern Surface Seal Installed by <br /> I i Irrigation �..Approx. <br /> State Work Done <br /> Repair Work Dane ❑ Type of Pump <br /> H P. <br /> Sealing Well Destruction ❑ Well Diameter Seag Material )top 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l I DESTRUCTION M (Noseptiwithin system rented if public sewer is <br /> availabInstallation will serve: Residence— Commercial— Other <br /> r <br /> Number of living units: Number of bedrooms Water table depth <br /> I 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. CI <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ Na. & Length of lines <br /> Total length/size <br /> FILTER BED' <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth i Size - Number ,• <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application and that the woik will be done insaccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations-of-the-San Joaquin Local Health Diltrict. <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 /> d 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 /> t ersons subject to workman's compensa- <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ p I <br /> - tion laws of California." <br /> The applicant must call for all required inspections. complete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date 'g y Area <br /> Application Accepted by �� / <br /> P <br /> Date Final Inspection by <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> r CK <br /> RECEIVED BY DATE PERMIT'NO. <br /> ffEAMOUNT DUE .' AMOUNT REMITTEDEH 43-24{REV.tin51 !� <br /> EH 14.26 <br />