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� y APPLICATION FOR PERMIT w � <br /> +` SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T Ofd AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N�'�rLii�� <br /> i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �r. ``� "J� (Complete in Triplicate) <br /> . This <br /> cation is <br /> t and/or <br /> all the work herein des <br /> Application is compliance with Sano the JoaquinnCounty Ouin rdinance No. 549 for sewage or ocal Health District for a permit <br /> No. 1862 forcwelUpump and the Rules and Regulations of the Sans Joaquin <br /> made in comp { <br /> Local Health District.. <br /> 1111 -g 11C E © Lot Size PM <br /> Job Address �ftj,116110­ k: <br /> x Phone <br /> Owner's Name Address <br /> J� <br /> r !\ 1 <br /> n to " <br /> I Address License No._Phone <br /> Contrac _ <br /> TYPE OF WELL/P BMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> OSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> " <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f' INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS Dia. of Well Casing <br /> f © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing r Specifications <br /> L1 Domestic/Private Ll Gravel Pack El Type of Grout--.. <br /> ❑ Public n Other Delta Depth of Grout Seal YP - <br /> ! i I Irrigation —Appro epth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Typ ump H.P. State Work Done <br /> Well Destruction ❑ ell Diameter Sealing Material )top 50'1 - <br /> Depth Filler Material (Below 501 - <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADUCTION`DITION l I DESTRalvailablelw thin 200 feetstemltled it public-sewer is <br /> t <br /> Installation will serve: Residence? Commercial_ Other <br /> Number of living units: Number of bedrooms a <br /> 4 Character of soil to a depth of 3 feet: Water table depth <br /> t - Capacity No.Compartments <br /> SEPTIC TANK ElType/Mfg <br /> PKG, TREATMENT PLT. El �. Method of Disposal _ a <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size } Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> 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 /> j. rules and regulations of the San Joaquin Local Health District. <br /> f 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 /> 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: "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 /> tion laws of California." <br /> F The applicant must ca o requi Ins tkms. Complete drawing on reverse side. <br /> J Signed X Title: <br /> Date: a V-97 <br /> R D EN LY O <br /> Application Accepted by — -7� nArea w <br /> Pit or Grout Inspection by Date Final inspection by �'�G✓`e , Q Tr�"'`� Date 3 r 3 �__�11 <br /> Additional Comments' <br /> ❑ Stk 466-6781 �Lodi369-3621 ❑ Manteca 1123-7164 ❑ Tracy 835-6385 G'w 4-r"lV_k1eceC) 6'+ 4tc44 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED A nECEIVED BY DATE <br /> INFO �TT'NO. <br /> EH 13-24{REV.i/K 51 <br /> EH 14-29 <br />