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SjoN <br /> APPLICATION FOR PERMIT " <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA SEP <br /> Telephone (209) 466-6781 ENVI f�P�SM �jjA� r � ill N <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'€RI��#MENTAt`l1✓E� <br /> (Complete in Triplicate) <br /> Application is hemade to the <br /> Joaquin Cou Qty O d nalncle No.549 for sewage or permit construct and/or herein <br /> No 1862 forwell/pump and the Rules andRegulations application of the SanJoaquin <br /> made in compliance with <br /> Local Health District. _ --LL <br /> City L# Lot Size PM <br /> Job Address <br /> Address . E}OL(� Phone 3 <br /> "'T—T <br /> Owner's Name <br /> Contractor Address <br /> 3 icense No. Phone <br /> WELL REPLACEMENT 01 DESTRUCTION El <br /> TYPE OF WELL/PUMP: NEW WELL El <br /> PUMP INSTALLATION ElSYSTEM REPAIR OTHER ❑ <br /> -- -- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION <br /> AGRICULTUREWELLOTkiER-WELL-------QTS/SUMPS _— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El industrial Specifications <br /> Bottom El Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> El Domestic/Private El Gravel Pack El Tracy Depth of Grout Seal T e of Grout --- <br /> ("1 Public ❑ Other ❑ Delta _ C_ <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _ <br /> Depth 1. Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system <br /> m emitted if public sewer is <br /> availabeet <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: No. Compartments <br /> SEPTIC TANK ElType/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE Ll No. & Length of lines Property Line <br /> FILTER BED El Distance to nearest: Well Foundation P y <br /> Size — Number <br /> SEEPAGE PITS l I Depth Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation <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. <br /> certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I <br /> employ any perso in such manner as to become subject to workman's compensation laws of California" Contractor's hiring or sub-contracting signature <br /> certifies the folio i g: "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 nia.,, <br /> The appfica call for all req it d inspe i ns. Complete drawing on, v rs side. <br /> Signed X <br /> Title: Date: <br /> R DEPARTMENT USE ONLY �/� p <br /> Date Area 0 <br /> Application Accepted by <br /> Date Final Inspection by <br /> Date% - 2 <br /> Pit or Grout 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 /> FEE CK RECEIVED BY DATE PERMIT"NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO (� <br /> a EH 13-241REV,1/N5) <br /> EH 14-26 <br />