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APPLICATION FOR PERMIT >� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT {� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA J z <br /> l <br /> Telephone (209) 466 6781 (� c��Q <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> or install the work <br /> cation is <br /> madApplication omplhance writhdSano the Joaqu Joaquin Qty Ordinauin lnHe Nth District for a o.549 for sewage or permit <br /> No. 1862 for cwell pump and the Runes and hereindescribed, <br /> of the San l Joaquin <br /> Local Health District. <br /> 0-03 City 42y� Lot Size PM <br /> Job Address <br /> Owner's Nam <br /> Address _ Phone <br /> l <br /> Phone <br /> dress Centra dress t 56 License No, aZ <br /> TYPE Of WELL/PUMP: NEW WELL ElWELL REPLACEMENT ID DESTRUCTION (71 , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack a Tracy Type of Casing Specifications <br /> {-I Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> t _ <br /> ° I I irrigation T Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> * H.P. <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> i <br /> Well Destruction ❑ We11 Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIRIADDITION I 1 DESTRUCTION (Noavaseptic <br /> system <br /> ithin m Perfee{i fed if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> _ ❑ Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> I� LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS f I Depth Size Number <br /> SUMPS ❑ Distance to neatest: Well Foundation Property Line <br /> lDISPOSAL PONDS ❑ ' r <br /> I 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 /> ffff 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 /> 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: "l 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." 1 <br /> t The applicant st II for alt equired inspections. Complete drawing pq reverse side: <br /> i Signed X Title: Date: <br /> ,FOR DEPARTMENT USE ONLY ` <br /> \ <br /> Application Accepted by _ i ..Date Area <br /> Pit or Grout Inspec by Da a Final Inspection by t Date-7 . <br /> I Additional Comments: T <br /> c <br /> ` © Stk 466-6781 ED] Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 935- <br /> E Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CKF <br /> a FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> 4 INFO <br /> ♦ EH 13-24(REV.1/M5) <br /> EH 14-28 <br />