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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 i E. HAZELTI ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> all the <br /> rk fieFein <br /> ribed.This SPPI <br /> Application is hereby <br /> madewith San Joaquin County Ordinance cation is <br /> le No.alth D549 for for <br /> or permit <br /> 1862 for weNlconstruct dpump atnd the ales and Regulations of the San r oaqu n <br /> made in complla -„ <br /> Local Health District. s e <br /> r <br /> city Lot Size PM <br /> Job Address _ ��7/ _ •/,'��c! <br /> hone <br /> 4 Owner's Name . <br /> Address <br /> f icense Na._� Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> M PUMP INSTALLATION Ll SYSTEM LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES -- DISPOSAL FLD.1�� — <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> .... - - ii <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial Specifications _ <br /> [Gravel Pack ❑ Tracy Type of Casing <br /> Domestic/Private / Type rout <br /> ❑ Public <br /> ❑ Other ❑ Delta Depth of Grout Seal t� <br /> € ❑ Irrigation _-4pprox: Depth ❑ Eastern Surface Seal Installed by <br /> H P State Work Done' <br /> Repair Work Done F1Type of Pump <br /> Beefing Material (top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'1 <br /> Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlailablelwithSne200 feet.) <br /> itted if public sewer is <br /> r <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> k Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ ! <br /> Foundation Property Line <br /> Distance to nearest: Well <br /> 4 Total length/size <br /> LEACHING LINE 1-1No. & Length of lines property Line <br /> FILTER BED <br /> L1 Distance to nearest: Well Foundation <br /> Size Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> k SUMPS ❑ Distance to nearest: Well Foundation <br /> is a DISPOSAL-PONDS-"--t—' =❑ -- <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 she not <br /> r employ any person;n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> { <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> c tion laws of C lifornia." <br /> r The appy ust call for al eq ed inspections. omplete drawing o r e de r <br /> Signed <br /> Title: <br /> Date: <br /> FOR D PARTMENT SE ONLY Q <br /> Date r Area J <br /> Application Accepted b Date <br /> Pit or Grout Inspection <br /> Da a Final Inspection by <br /> Additional Comments: <br /> LlStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to-. Environmental Health Permit/services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTER C RECEIVED BY DATE nM1T6NO- <br /> F7FEE <br /> + EH 73-24(REV.1/86) �j� <br /> EH 14-26 <br />