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APPLICATION FOR PERMIT <br /> e j <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Jae n1601 E. HAZE T ON AVE., STOCKTON, CA 1 <br /> v, 1.z "{J � Telephone (209) 486-6781 <br /> U ILA-1 PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the <br /> rk <br /> . This <br /> cation is <br /> Application is hence with Sanothe JoaquinnCoumy Ordinauin nce Nth District for a o.549 for sewage or permit <br /> No 1862 forcwellldpump atnd the Rues and IR Regulations of the San Joaquin <br /> made in compliance <br /> Local Health District. <br /> City. Lot Size PM <br /> Job Address �� f� <br /> Owner's Name <br /> Address Pho,7 <br /> f' 3 .� <br /> Contractor Address 96 N Phone'; License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q <br /> DISTANCE TO NEAREST: SEPTIC TANK A" SEWER LINESDISP <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ ca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy E Type of Casing Specifications <br /> [I Public F1 Ot F1 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —.-Approx. Depth l'I Eastern S (ace Seal Installed by <br /> I State Work Done _ `V <br /> Repair Work ❑ Type of Pump H.P. -• <br /> We struction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Allaferial-Il3eloW50 � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION J I REPAIR/ADDITION l i DESTRUCTIO (No septic system permitted if public sewer is <br /> i vailable within 200.feet.) <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 /> `I , r Method of Disposal PKG. TREATMENT PLT. ❑ �� � � i <br /> l <br /> Distance to nearest: Well FoundationProperty.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS L-1 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 /> i 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: "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." I <br /> The applicant mus call for al) required inspections1 Complete drawing on reverse side. � 1 <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I Application Accepted by Date 'S Area r <br /> Pit or Grout Inspection b Date Final Inspection.b Date '60 <br /> Additional Comments: <br /> 0 Stk 466-6781 El Lodi 369-3621 ❑ Manteca 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 /> I <br /> FEE AMOUNT DUE AMOUNT REMITTEDC SH RECEIVED BY DATE PERMI-rNO- <br /> INFO dc <br /> a.EH 13.24 IREV.I i n 51 <br /> l EH t4-26 <br />