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r <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE'-T ON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> (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 /> e or Na.,1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District. Q k <br /> city A tot Size PM <br /> Job Address _ <br /> Address Phone <br /> Owner's Name y s > <br /> Z � <br /> License No_ Phone <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEWELL ElWELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION E-1SYSTEM REPAIR ❑ OTHER <br /> DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casino Type of Grout <br /> ❑ Public ❑ Other i ❑ Delta Depth of Grout Seal <br /> El Irrigation —�`pp <br /> ox.-Depth C1Eastern Surface Seal Installed by { <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> ' Well Destruction ❑ Well Diameter <br /> Sealing Material {top 501 <br /> _` Below'50 <br /> Depth -Filler Material I '1 <br /> er <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION DESTRUCTION 13alvailabletwithin 20sm 0 feetttted if public sewer is 1 <br /> i Installation will serve: Residence Commercial_ ther , <br /> Number of riving units: Number of bedro ms �. <br /> p yv� Water table depth <br /> Character of soil to a depth of 3 feet: L I? <br /> Capacity �Z��2 No. Compartments <br /> I SEPTIC TANK ❑ Type/Mfg Method of Disposal ?, <br /> PKG. TREATMENT PLT. ❑ tj <br /> i 8 Property Line_ <br /> Distance to nearest: Well Foundation <br /> ,. ��� _irk'} , ,at tengthlsize_� <br /> LEACHING LINE Fr'—No. & Length of lines ' _ _ <br /> FILTER BED ❑ . Distance to nearest: Well_ S Foundation,3 Property Line/O a <br /> a <br /> SEEPAGE PITS ❑ Depth Size Number { <br /> SUMPS ❑ Distance to nearest: -Well Foundation Property Line <br /> �r <br /> DISPOSAL PONDS ❑ <br /> l hereby certify that I have prepared this application and that the work will be done in accordance with S <br /> Thereby <br /> 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 /> P employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 Californ ." <br /> The applicant mu quired inspections. Complete drawing on reverse side. � q <br /> Signed Title: <br /> V.3 I.] Date: �—S 4 — <br /> FO EPA gMENT USE ONLY <br /> § _ <br /> DateArea <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> �r �to M4rs <br /> Sacd �sfzl��( c4.. 1 Ps a d a� w550-ecl�� ! <br /> Additional o meets: ` " ! <br /> 1 Tracy 835 6385 <br /> ElStk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> rNFO � <br /> +EH 13-24(REV. ' <br /> EH%28 �- <br />