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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> .This application is <br /> Application is hereby made to the nJoaquin <br /> Ordinance lHealth District for a It to construct No. 1862 for well/dpump and the Rules and/or inall the work herein <br /> R gulations of the Sanl Joaquin <br /> made in compliance with San Joaquiui County tYNo.549 for sewage or , <br /> Local Health District. <br /> City CxV6` Lot Size �r` —=PM <br /> Job Address <br /> cif a �' t!i 2 'Phone <br /> Owner's NameC ra. Address 4rZ <br /> cl 7 License No f Phone C[` Ie <br /> Contract YLLe 4L Address �� q�l "Y �� <br /> TYPE OP WELL/PUMP: 11 NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION EJ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ElOTHER El <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing (� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications 7 <br /> ❑ Domestic/Private ❑ GraType of Casingvel Pack ❑ Tracy <br /> ❑ Public ❑ Other El Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth 11Eastern Surface Seal Installed,by <br /> State Work Done <br /> Repair Work Done ❑ Type <br /> of Pump H.P. • <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth ' r Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [IEPAI , ADDITION DESTRUCTION ElavailableNo lwithin 200 feet .)ermi if public sewer is <br /> Installation will serve: Resi/deuce _�, Cercial_ Other <br /> Number of living units:—<— Numfier�ofedroom Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> No. & Length of lines total length/size / <br /> LEACHING LINE % property tine � <br /> FILTER BED El Distance to nearest: Well — Foundatibn <br /> !�f{� Number <br /> SEEPAGE PITS ®' Depth Size r �� <br /> SUMPS 11Distance to nearest: Well Foundation /0 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, and <br /> rules and regulations of the San Joaquin Local Health District. work for this permit is issued, <br /> eHomemploy <br /> owner a stone n such mannerastorbecomfies the following: "I e subjects to workman's clfy that in the ompensation laws ormance of of California."Contractor's which <br /> ng or sub-contracting lsignlature <br /> emp y Y P persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call for I re fired inspections. Complete drawing on revere side. C <br /> Title: Date:�#— <br /> ki <br /> Signed <br /> s <br /> FOR PARTM T USE ONLY <br /> Date Area <br /> Application Accepted by 7–5 <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Dade <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +EH 13-24(REV.1/a 5) eS �J <br /> EH 14-26 <br />