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APPLICATION FOR PERMITS_ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ? 1601 E. HAZETON AVE., STOCKTON, CA �ad Cp . <br /> Telephone (209) 466-6781 l <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) � �` <br /> all <br /> the work <br /> describe , This <br /> cation <br /> made iis <br /> n ompliance werebyith SanoJoaquin the nJoaquin Comy ordinalncle No. 549 for sewage or ealth District for a permit <br /> No. 1862 forcwell/pump atnd the Rules and IR gulations of the San <br /> r Joaquin <br /> Local Health District. <br /> n✓ City Lot Size PM <br /> ,lob Address <br /> r11 ' Phone Q <br /> Owner's Name. I Address - <br /> r � I <br /> Contractor Addres License No Phone <br /> TYPE OF WELL/P MP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP <br /> INSTALLATION D <br /> .f SYSTEM REPAIR ❑ <br /> OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES . DISPOSAL FLD. PROP/FINE <br /> FOUNDATION AGRICULTURE.WELL OTHER WELL PITSfSUMPS <br /> INTENDED USE Tl E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> d Industrial EIOpe'A,$ottom LJ Manteca Dia: of Well Excavation iDia. of Well Casing <br /> El Domestic)Private ❑ Gravel Pa 17 Tracy .` Type Specifications <br /> e of Casing <br /> Other �� fi r Type of Grout <br /> FI Public Fl ' Depth of Grout Seal f <br /> I l Irrigation _" ..Approx. Depth`'4�Eastern Sup ace Seal Installed by <br /> Repair Work Done ❑ Type of Pump fie` H.P. State Work Done_ <br /> alin Material (top 50'1 t <br /> Well Destruction ❑ Well Diameter 9 � <br /> Depth i Filler aterial (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDI N i I DESTR TION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> I Installation will serve: Residence Commercials Other <br /> 4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> F <br /> No. Compartments <br /> SEPTIC TANK ❑ ','Type/Mfg Capacity w <br /> A. �� f Method of Disposal <br /> PKG. TREATMENT PLT. ❑ f <br /> Distance to nearest: Well/ Foundation P erty Line <br /> r � <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of tinge' 1 <br /> FILTER BED ❑ Distance to nearest/: Well Foundation Property Line r <br /> Number <br /> SUMPS <br /> SEEPAGE PITS [ I Depthr Size — <br /> SUMPS L71Dish. to nearest: Well Foundation Property Line <br /> J <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin county ordinance tate laws, and <br /> rules and regulations of a 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 s all.not <br /> employ any persoun such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the foll6wing: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's Compensa <br /> tion laws of California." r <br /> The.applicant st for quer ins ctians. Com to drawing on reverse side. D <br /> Signed X_ <br /> Title: &Z�7Date: <br /> 11 <br /> nnqq FO DEPARTMENT USE ONLY <br /> �\ f <br /> Application Accepted by ��t'` Date �-C7 1 � Area 4 <br /> �!L7 <br /> Date GIZ <br /> Pit or Grout Inspection by Final Inspec'on a <br /> I dditional Comments: ign�"Z R" <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 5 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Gill(g2, E _ <br /> FEE AMOU�DUEAMOUNT REMITTEDRECEIVED BY DATE PERMIT IVO. <br /> INFO <br /> qa--� S g <br /> l + EH 1324IREV.t/Hsl �� ti) Q <br /> EH 14-29 <br /> u s <br />