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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />,. 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 <br /> Telephone (209) 466-6181 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> laquin <br /> •(Complete in Triplicate) <br /> Thris <br /> PPA lication is hereby made to the San Local Health District for a permit tto;own for well/pump and the Rules and Regtruct and/or install the work herein du cribed of the Sanppli Joaqu n <br /> altion is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage o <br /> Local Health District.. <br /> City Lot Size PM <br /> Job Address <br /> 9 y <br /> Phone <br /> Owner's Name <br /> dress �' <br /> I <br /> License No.�_. —Phone <br /> Contractor Address <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 13 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES �— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL LINES/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU CIFICATIONS Dia. of Well Casing w <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Excavation <br /> " Type of Casing Specifications <br /> [3 Domestic/Private ❑ Gravel Pack - <br /> g Type of Grout <br /> El Public ❑ Other El Delta Depth of Grout Seal y. <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed-byX <br /> l <br /> H.P. State Work Done <br /> Repair Work Done Type of Pump <br /> { Well De ion C] Well Diameter Sealing Material (top 5D') <br /> 1 Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 204 feet.) <br /> 5 <br /> q 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: r No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity - <br /> f Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation ,Property Line <br /> r + Total length/size <br /> LEACHING LINE [2No. &Length of lines Property Line <br /> i FILTER BED ❑ Distance to nearest: Well Foundation <br /> SEEPAGE PITS ❑ Deptfi Size Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ITThereby certify that 1 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. ormance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perf <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub contracting 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 taws of California." i <br /> The applicant must call for all re uId inspections. Complete drawing on reverse side. �s_ <br /> r Date: <br /> S gned Title: <br /> {j FOR DEPARTMENT USE ONLY <br /> i Date Area <br /> Application Accepted by �J' IG <br /> Pit or Grout Inspection <br /> Date Final Inspection by Date <br /> p_Additional Comments: <br /> ❑ Stk 466-8781 ❑ Lodi 369 3611 ❑ Man 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> RECEIVED By DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH f <br /> +EH53INFO 241REV.}�e5Y 'U� _ P <br /> EH 1426 <br />