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APPLICATION FOR PERMIT <br /> r SAN JOAQUIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON'AVE.,'STOCKTON, CA <br /> Telephone (209) 466-6781 r <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 Lto construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for swage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> tt r 4 <br /> Local Health District. . <br /> ' <br /> 1 a.z0,n.� City Lot Sizee PM <br /> Job Address _ '•"` <br /> Address —_ Phone <br /> Owner's Name l� I <br /> Contractor <br /> Address �! d License No. phoneOJ`� ` > <br /> TYPE OF WELL/PUMP: NEW WELL F7WELL REPLACEMEN_' t_p DESTRUCTION El <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> I <br /> Domestic/Private ❑ Gravel PackTracy T e of Grout <br /> ❑Public ❑ Other ❑ Delta Depth of GroiirSeal yP <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump,— H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 b <br /> Depth Filler Material IBeIow 501 CN <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION [3iNo septiclable sy tem permitted if public sewer is <br /> fInstallation will serve: Residence_ Commercial_ Other- <br /> Number <br /> therNumber of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> _U <br /> Method of Disposal <br /> k PKG. TREATMENT PLT. ❑ <br /> 1 Distance to nearest: Well Foundation Property Line (} <br /> 4 <br /> Total length/size <br /> LEACHING LINE LlNo. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: F Well Foundation Property Line <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 /> 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 /> mpensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <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 California." <br /> The applicant must ll for all equired inspections. Complete drawing on reverse side. <br /> { _ <br /> Date: 4a <br /> Title: <br /> Signed -- <br /> ---FOR"'c�FOR DEPARTMENT USE ONLYf <br /> Date 2v � Area <br /> Application Accepted by <br /> r Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C1 Manteca 823-7104 El 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 /> + EH 13-24(REV.5/85) <br /> EH 1426 i <br />