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APPLICATION FOR PERMIT 9 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA j <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> in <br /> rk <br /> . This <br /> Application is hereby madeto the u n County Qty O d nalnce No. 549 for sewage or Health District for a Permit to <br /> 1862 for cwell and/orinstall <br /> and the Rhes and IReg Regulations of the San l Joaquin <br /> made in compliance with S q <br /> Local Health District. <br /> Cl ^ City G 6et-Lot Size �sd X G PM <br /> Job Address / n�,/ <br /> j� Phone <br /> Owner's Name <br /> +" d <br /> "Address <br /> i License No._ Phone <br /> Contractors Address <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: _ SYSTEM REPAIR ❑ OTHER ❑ <br /> i PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD- PROP. LINE TO NEAREST:.SEPTIC TANK R - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE • TYPE,OF WELL_ PROBLEM AREA CONSTRUC710N SPECIFICATIONS pia. of Well Casing l <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications i <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Depth of Grout Seal Type of Grout — <br /> ❑ Public f_! Other ❑ Delta <br /> I 1 litigation —.-Approx. Depth i I Eastern Surface Seal installed by <br /> i H P State Work Done <br /> Repair Work Done ElType of Pump <br /> (top 50'1 <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material <br /> Depth Filler Material (Below 501 <br /> te TYPE OF SEPTIC WOflK: NEW INSTALLATION 1.1 REPAIRlADDITION 'l DESTRUCTION aNailabpelw thin 200 feetc system ltled if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water 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. ❑ Property.Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE= ❑ No. & Length of lines Property Line <br /> FILTER BED E] Distance to nearest: Well Foundation <br /> i <br /> lI Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS Ll Distance to nearest: Wel Foundation <br /> DISPOSAL PONDS • . -_❑ <br /> I hereby certify that I have pepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> r <br /> rules and regulations of the San Joaquin Local Health Di1trict. <br /> Home owner or licensed agent's signature certifies the following: "l 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 /> certifies the following: '9 certify that in the performance of the work for which this permit is issued,t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must cal for all required inspect ns. Complete drawing on reverse side. <br /> itle: <br /> Signed X <br /> ate: <br /> FO DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by f <br /> Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Date ..-X <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 /> FEE CK RE EIVED BY DATE PERMIY'NO. <br /> {NFO AMOUNT DUE AMOUNT REMITTED ASH <br /> +.EH 53-24 IREV.t/M 57 , <br /> EH 14-28 <br />