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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 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 /> or No. 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 sewage <br /> Local Health District. <br /> �j Size PM <br /> Job Address �/- �/ City �T> >f Lat / 7 PM <br /> ` I <br /> Owner's Name s Phone <br /> Contractorss License No Phone <br /> TYPE OF WELL/PUMP: NEW WELL I] WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of,Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 4 r <br /> PI Public 11 Other D Delta Depth of Grout Seal Type of Grout = <br /> I I irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work-Done ❑ Type of Pump H.P. State Work Done Q <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIR/ADDITION I I DESTRUCTION I I allo septic system permitted it public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence_L_Commercial'— Other <br /> Number of living units: _ ,Number of be rooms 4 - w <br /> Character of soil to-a depth of 3 feel: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments <br /> PKG. TREATMENT-PLT. ❑ .e Method of Disposal <br /> Distance to nearest: Well Foundation ___._ Property Line <br /> LEACHING LINE No. & Length of lines - Total'lengthlsize <br /> FILTER-I3E�"-- O—Distance-to nearest: Weil _ �._ Foundation Property Line <br /> P _-- . - S. B r " <br /> SEEPAGE PITS+f ai IJ Depth Number <br /> UMPS Ll Distance to nearest: Well Foundation O`IL-Property Line ' <br /> DISPOSAL PONDS ❑ <br /> ,f 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. w ` <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 /> employ any person in such manner as to become subject to workman's compensation laws of California ." Contractor's 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 laws of California." <br /> The applicant fnvst call for aka requ' inspections. Complete drawing on revwe-side. <br /> Signed X Title: v Date: <br /> ! R DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 / Area <br /> Pit or Grout Inspection by ate Final Inspection by Date <br /> �,� o K tom' <br /> Additional Comments: � _S �� 6,01� <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I F <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> - CKRECEIVED-13Y DATE PERMIT'NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +.EH 13-24(REV.I/n s) <br /> EH 14-29 <br />