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APPLICATION FOR PERMIT <br /> 1° SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> No <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .This <br /> cation is <br /> n desc <br /> Application is hereby made n the San Joaquin Ordinalncfe No.549 for sewage or ealth District for a permit <br /> No 1862 forct and/or install the work well//pump and the Rules and'R Regulations of the San Joaquin <br /> made in compliance with San Joaquin County <br /> Local Health District. <br /> ,.t £ City ___% c_ Lot Size PM <br /> Job Address <br /> ��.A, Phone <br /> Owner's Name ' /p s Address <br /> ��✓!� License No. <br /> 1�Q/1� Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES _--- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS <br /> a <br /> AGRICULTURE WELL <br /> IFICATIONS t , <br /> INTENDED USE LL PROBLEM AREA CONS Dia. of Well Casing W <br /> ❑ ❑ Mante Dia. of Well Excavation <br /> ❑ Industrial Type of Casing Specifications <br /> ❑ Domestic/Private racy Type of Grout--- <br /> n <br /> M l Public <br /> ❑ Delta Depth of Grout Seal <br /> I I Irrigation epth l I Eastern Surface Seal Installed H.P. State Work Done_ <br /> ^` <br /> Repair Work Done ❑ Type of Pump Sealing Material (top 50'1 <br /> Well Destruction El Well Diameter r <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAtR/ADDITION ( I DESTRUCTIO NailabPe1wit hine200 feet.) 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: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line <br /> Distance to nearest: Well <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line <br /> FILTER BED El Distance to nearest: Well <br /> SEEPAGE PITS I I Depth <br /> Size Number <br /> SUMPS ❑ Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, an <br /> rules and regulations of the San Joaquin Local Health District.g work for <br /> Home owner or licensed insuch manner as torbecome subject Ito workman's <br /> rtcompensation lify that in the awsoof California." Contractor's 1r' lhir ng orr sub-contracting signatuthis permit is issued, I shall re <br /> employ any person <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 t call for all requtr ins ctions. Complete drawing on reveresside. <br /> CJ <br /> � Title: Date: <br /> Signed X <br /> DEPARTMENT USE ONLY �^ <br /> Date Area �p <br /> Application Accepted by Date <br /> Date___ -- Final Inspection by <br /> Pit or Grout Inspection by c <br /> Additional Comments: y—/Y"� 0 5 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Stk., CA 95201 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK DATE PERMIT NO. If <br /> FEE MOUNT DUE AMOUNT REMITTED C H RECEIVED BY <br /> INFO <br /> + EH 13-24(REV.t/H5) <br /> EH 14-28 <br />