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wi <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> D4 Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 9f3oo E. 40-6-kyvpo (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance Nofor sewage or No. 1862 fo�r7weell/_pump and the FWs and R ulations of the San Joaquin <br /> Local Health District 4CI <br /> Job Address <br /> Ci "Lot Size �b / <br /> �y ,h/ ) 4 y <br /> Owner's Name Y Address �""' a Pho ex <br /> zzz <br /> Contractor's Name icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL`❑ WELL REPLACEMENT ElDESTRUCTION ElPUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK rr �� SEWER LINES DISPOSAL FLD. `. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> X <br /> rigation �pprox. D €astern Su ce Seal Installed byepair Work Done Type of Pump �d�e H.P. State Wo Done <br /> Well Destruction F-1 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if pu lic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <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 ❑ 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 /> 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 /> The applicant 1pust call r all required insdrawing on reverse s <br /> pecti ns Complete id �+ <br /> Signed Title: Date: _17O <br /> FOR DEPAR MENT USE ONLY <br /> 12- <br /> Application Accepted by v Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date A1- 2$ <br /> Co ms <br /> Addition Co menta: Cdr C U <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 At Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> + EH 13-24(REV.10/83) . <br /> EH 14-28 <br />