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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT M <br /> t . <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA S�Pryr <br /> Telephone (209) 466-6781 7 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED ENVIRONMENTAL H'PAL.TI-i <br /> (Complete in Triplicate) PERMIT/SERVJC,,�. <br /> /or install the work <br /> n describe . This <br /> cation is <br /> Appication <br /> nt'coompliance withdSanoJoaqu nthe SanCoungty OrdinaJoauin lnc{e No.549 for sewage or ealth District for a permit <br /> No. 1862 forcwell/dpump and the Rules and'R gulations of he Sans Joaquin <br /> Local Health District. ' <br /> 20ELL/ <br /> PM <br /> City Lot SizeJob Addled.Owner'sAddress Phone <br /> ContracAddress �• icense No Phone <br /> TYPE OF PUMP: EW WELL WELL REPLACEME ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION— SYSTEM REP ❑ --- O HER <br />" DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FILO. ROP_LINE <br /> FOUNDATION AGRICULTURE WELL ' OTHER WELL yo 1 PITS/SUMPS <br /> INTENDED USE TYP OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N <br /> i/ <br /> ❑ Ind trial pen Bottom ❑ Manteca Dia. of Well Excavatio /Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> Ot�er F1 Delta Depth of Grout Seal T e of Grout -_ <br /> FI Public r <br /> I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ype of Pump H.P. — � State Work Done <br /> Well Destruction ❑ Well Diameter _ /r— Sealing Material (top 501 — <br /> Depth `�/ Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septiwi hinem emitted if public sewer is <br /> avaeet <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 `n <br /> Distance to nearest: Well Foundation Property Line v <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS -. I I Size. <br /> Number - <br /> SUMPS ❑ Distance to nearest: Well 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, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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 no <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: "1 certif that in the rformance of the work for which this permit is issued,.1 shall employ persons subject to workman's compensa- <br /> tion laws of Califor <br /> The applicant mu all for all equir pectio s.,Complete drawing on r v r e side <br /> Signed X <br /> itle: Date: <br /> F EPARTMENT USE ONLY ® / `! <br /> Application Accepted by Date Area n �7r <br /> r �.. YJ "// ODate <br /> Pit o Grou Inspection by Date Final Inspection by <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 SFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE LPERMITNO. <br /> INFO a.EH 13-24(REV.t/R5) . ' `fI � <br /> EH 14-26 <br />