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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> made n con liance with haseby dSin Joaquin County ordinaLocal <br /> nce No. 549 for sewage orpermit <br /> No. 1862 forconstruct <br /> welifdpump and the Runes and herein <br /> Regulations of tthe Sanapplication <br /> Joaquin <br /> made in compliance <br /> Local Health District. <br /> Job Address <br /> 3 Cit Lot Size PM <br /> Owner's Name <br /> Address Phone <br /> F Address License No. Phone �� <br /> Contractor <br /> TYPE OF ELLIP P: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Casing <br /> Dia. of Well ` <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g <br /> ❑ Domestic/Private LJ Gravel Pack ❑ Tracy <br /> Type of Casing Specifications <br /> F1 Public ❑ Other Ll Delta r Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth I f Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' <br /> Well Destruction ❑ Weil Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDI TION l I DESTRUCTION 1 INosepttic System <br /> hin m emitted if public sewer is <br /> kInstallation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Capacity— Water table depth (Q <br /> Type/Mfg, <br /> City No. Compartments <br /> SEPTIC TANK ❑ I*' <br /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size C <br /> ' FILTER BED ❑ Distance to nearest: ` Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: 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 Diltrict. <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 /> lion laws of California." <br /> The applicant cal I re d nspections. Complete drawing on reverse side. / <br /> Signed X Title: ,�„ « Date: <br /> ART_MENT USE ONLY �) <br /> Application Accepted by Date Area [� <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK 4 RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> I ♦.EH 13-21 IREv.1 i H 5)1 <br /> EH 11-26 <br />