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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ,,PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I This cation is <br /> ' <br /> Application is hereby made to the San Jouh u1 Local Health Ord Hance No.District549 for sewage or permit <br /> 1862 forcwell/pump and the Rules and-Regulations of the Sa Joaquin <br /> made in compliance with San Joaquin C ' ty <br /> Local Health District. �/ U <br /> r'1 X PM <br /> 03 /'17' )4 ��� City Lot Size <br /> Job Address p� CJ <br /> /�� <br /> /� W-� Address © Phone T��] <br /> Owner's Name MIJ - s <br /> N ( License No. =--Phone <br /> Address <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER Cf <br /> PUMP 1NSTALLATIONfd SYSTEM REPA <br /> 4� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAR PTIC TANK SEWER LINES <br /> . PITS/SUMPS <br /> 4 FOUND � <br /> 4- AGRICULT ELL OTHER WELL <br /> INTENDED USE TYPE OF WELL 13 M`AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom Monte Dia, of Well Excavation <br /> E ❑ industrial t Specifications <br /> r ❑ Tracy � ri of Casing <br /> ❑ Domestic/Private ❑ Gravel Pa Depth o t Seal Type of Grout <br /> ED] 4 ❑ Delta <br /> fl Public PproxSurface Seal Instal e <br /> ❑ Irrigation J4 . Depth ,f�❑ Eastern State one <br /> ,�' H.P. •. ` z' , <br /> Repair Work Done ❑ Type of Pump f0 Sealing-Material (top 501 <br /> Well Destruction ❑ Well Diameter,,, � �, <br /> Depth V Filler Material (Below 50'I <br /> available wi in, feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITI4N ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> installation will serve: Residence i Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: ,' CapacityNo. Compartments <br /> XT e . <br /> SEPTIC TANK yp /Mfg <br /> Method.of Disposal <br /> PKG. TREATMENT PLT. ❑ pro a Line <br /> Distance to nearest: Well Foundation ' p ' <br /> i i fl Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property tine <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation` <br /> ❑ Depth t Size Number <br /> f SEEPAGE PITS Foundation Property Line <br /> h SUMPS ElDistance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> , )(cation and that the,work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> 1 <br /> k I hereby certify that I have prepared this app <br /> rules and regulations of the San Joaquin Local Health olio in/g. <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shallnot <br /> employ any person in such manner n to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"1 certify that i;the performance-of the work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> tion Paws of California." <br /> + The applicant ca f a aired inspections. mplete drawing on reverse side. Date: <br /> k Title:-� ` <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bDate <br /> e <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> r Additional Comments: ❑Tracy 89`.-6385 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 <br /> Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009 <br /> Applicant - Return all copies to: , Stk., CA 95201 <br /> I CKRECEIVED BY DATE PERMIT`NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO � / � 87-2N <br /> l <br /> + EH 13-24(REV.1/a 5) <br /> I EH 14-28 <br />