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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 ' <br /> K 1601 E. HAZE.TON AVE., STOCKTON, CA M) W <br /> WcrLU419-k <br /> Telephone (209) 466-6781 �4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �(� <br /> (Complete in Triplicate) C4 T <br /> .This <br /> cation is <br /> t and/or install the work <br /> n descri <br /> Application is ante with Sanothe San Joaquin)Joaquin County Ordinalncle No.549 for sewage permitealth District for a No. 1862 forcwe well/pump and the Rules and IR Regulations of the San Joaquin <br /> made in comp , <br /> Local Health District. <br /> 1 City S�- Lot Size PM <br /> Job Address {7 <br /> Owner's Name r <br /> Address 7 J Phone q Z <br /> i <br /> Contractor Address <br /> License No._Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L3OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK "SEWERLINESDISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> 11 Industrial ❑ Open Bottom [7 Manteca Dia. of Well Excavation Specifications <br /> Type of Cas] <br /> ❑ <br /> Domestic/Private ❑ Other Pack ❑ Tracy Type of Grout <br /> {`I prtblic ❑ Other r f:l Delta of Grout Seal - <br /> I Irrigation _.-Approx. Depth tern Surface Seal Installed by <br /> Repair Work Done ❑ Ty p'_— --- <br /> H p State Work Done <br /> Well Destructio Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material (Below 501 <br /> TION l INa septic system permitted if public sewer is <br /> REPAIR/AD <br /> /ADDITION l I DESTRUC - <br />� TYPE OF SEPTIC WORK: NEW INSTALLATION I i available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Othdr <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ] Depth Size _ Number <br /> SUMPS L-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll <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 District. <br /> k 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 /> 4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring csub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's campensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. $ 7 <br /> . Date: <br /> Signed X Title: <br /> t _ F EPARTMENT USE ONLY <br /> Date �C7� - Area <br /> Application Accepted bye <br /> Pit or Grout Inspection by <br /> Date Final Inspection b Date <br /> Additional Comments: <br /> El <br /> 466-6781 ❑ Lodi 369-3621 . ❑ Manteca a23-7104 ❑ Tracy 835-6385 ,�p�. <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 N <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> a EH13-24IREV.1/rill ��•OO ��� J��l �� !� <br /> EH 14-2e <br />