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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 /> 1kLatlOn 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 /> Application <br /> or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> r r PM <br /> .-, 1d City Lot Size <br /> Job Address <br /> el Phone <br /> Owner's Name Address 1 <br /> ' <br /> Address License Na. Phone <br /> ContractorDESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL El OTHER REPLACEMENT ❑ <br /> PUMP INSTALLATION 1-1SYSTEMREPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK �� .� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation <br /> ❑ Industrial Specifications <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Delta Depth of Grout Sea! Type of Grout <br /> ❑ Public ❑ Other Surface Seal Installed by <br /> ❑ Irrigation ---Approx. Depth CI Eastern State Work Done <br /> Repair Work Done L) Type of Pump H.P. <br /> Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Belo '! <br /> Depth <br /> PE EP <br /> OF STIC WORK: NEW INSTALLATION PAIR/ADDTION IDESTRUCTION ❑ alvailabl� <br /> ew thin permitted if public sewer is <br /> 200 feet <br /> TY <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: —/— Number of edrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ . ` . D' <br /> 8L) Foundation Property Line <br /> Distance to nearest: Well�— <br /> �, Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> ❑ Depth Size Number <br /> SEEPAGE PITSPropertyLine <br /> SUMPS ❑ Distance to nearest: Weil Foundation <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <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 /> ubject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become s <br /> certifies the following: "I certify that in the performance of the work for which this permif is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu_ all for all re ired inspections. mplete drawing oryTerse side. r <br /> Title: <br /> ��,�i;ii't�p r, Date: <br /> Signed <br /> FOR DEP ENT USE ONLY 7 Area <br /> Date <br /> Application Accepted by s� �� <br /> Date /r <br /> Pit or Grout Inspection by <br /> Date �� •Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> CK RECEIVED BY DATE PERMIT'NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> + EH 13-241REV.1/351INFO 7��� <br /> EH 14-26 <br />