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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I&AaVIVig <br /> .V 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> U ! Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (Complete in Triplicate) <br /> Application is heieby.made to the San Joaquin Local Health District for a permit to construct and/of install the work herein d Scribed. This application is ' <br /> made in compliance with San oaquin County Ordinance No. 549 for <br /> �se/age or No. 1862 for welllpump and the Rules and ulations of the San Joaquin <br /> Local Health District. ti� a/`tC /�- <br /> �� C City of Size PM <br /> Job Address � p <br /> � Phone <br /> Owner's Name Address <br /> 64 �� Phone <br /> Contractor Address License No. <br /> E TYPE OF WELUPPMP: NEW WELL E71 WELL REPLACEMENT El # ESTRUCTION + <br /> PMP INSTALLATION ❑ SYSTEM REPAIR ❑ —OTHER-0-- <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLIP. PROP. LINE <br /> ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTEND : USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia- of Well Casing ' <br /> EI Industrial } Open Bottom El Manteca Dia. of Well Excavation f <br /> } u Type of Casing Specifications <br /> ❑ Domestic/Private 1A Gravel Pack ❑ Tracy <br /> r - <br /> Type of Grout 1 <br /> M Public � Other � F1 Delta Depth of Grout Seal � <br /> I I I Irrigation � .-Approx.. H P State Work Done <br /> Depth . l i Eastern Surface Seal Installed by Iwoo <br /> i Repair Work Done IJ% Type of Pump <br /> Well Destruction )d] Well Diameter _.. Sealing Material (top 50'I - <br /> t�4 <br /> Depth _ -- _ ller=Material-I.Below-50'1- ry <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI M1I I i PA7R/AD.DITION I 1 DESTRt�CTI I i alvailablelwthin 200 feetitled if public sewer is <br /> Installation will S rve e, Residence+ j Commetc,ial Other ---._. _- <br /> Number of living units: <br /> Numbei of bedrooms <br /> a Water table depth <br /> Character of soil to a depth of 3 feet: " <br /> Capacity 7 t' No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg + a I f <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> }I Distance to nea esu t���Well 4 foundation Property.Line <br /> LEACHING LINE ❑ Not&'Length of lines 17-1 <br /> v E 1 r Total length/size <br /> [ FILTER BED ❑ Distance to nearest: Well Foundation Property Li e <br /> Number <br /> SEEPAGE PITS } I I Deptfi' Size's <br /> r �4L, e F;Foundatio�t Property Line <br /> SUMPS Cl Distance to nearest: Welles._- �# „� <br /> DISPOSAL PONDS ❑t- f <br /> I hereby certify thfat I have prepared this application and tha 'he work will be done in accordance with San Joaquin county ordinances, state Laws, and _ <br /> l rules and regulations of the''S'arl,-Joaquin L5'cal Health District. <br /> i Home owner or licensed ag'en's signafure certifi�e§,Sh!} ollowrng_ ' I certify that in the performance of the work for which this permit is issued, I shall not <br /> signature <br /> employ any person in such manner,as to,become subject\to workman's compensation taws of California Contractor's h sub act a workman'iring or rsgcompensa- <br /> certifies the following: "I ceriify that in the 00 orrm ,bf the work for which this permit is issued, I shall employ p 1 <br /> lion laws of Califo=rnia." J <br /> \�f� . <br /> The applicant mu <br /> r airedgrrtplete drawing on raver a side. <br /> Title: Date: <br /> Signed X l <br /> �F"11 EPARTMENT U�101NLY� l <br /> I Date_ i^ a O _ Area S <br /> Application Accepted by ` <br /> ` Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Retur!all copies'to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> i r <br /> I F� - <br /> FEE CASH RECEIVED BY jDAT;EjM4' .'"+moi <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> 3� � rn <br /> a.EH 13,24(REV.1/e 51 ' <br /> EH 14-26 <br />