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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> madlecn compliance with SanoJoaquin Counqty Ordinathe San Joauin lHealh District for a nce Nto.549 for sewage ormINo. 1862 forconstruct <br /> well/and/or <br /> mp and the Rules and herein <br /> R gulations of the Sanapplication <br /> Joaquin <br /> Local Health District. .11 r <br /> City Lot Size PM <br /> Job Address <br /> Owner's Name Z Address /��/� �' — Phone <br /> /� Address License No. Phone <br /> Contracto <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ _ PITS/SUMPS _ } <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial [J Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Specifications <br /> LJ Domestic/Private EJGravel Pack ❑ Tracy Type of Casing <br /> I`1 Public <br /> Other ❑ Delta Depth of Grout Seal Type of Grout—.--- <br /> torn <br /> I I Irrigation _.-Approx. Depth I I EasEastern �urface Seal Installed by State <br /> Work Dane <br /> - <br /> Repair Work Done ❑ Type of Pump H.P- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> .. Depih Filler Material (Below 501 '" -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I .DESTRUCTION t I (No septic system permitted if public sewer is S <br /> "' ,available within 200 feet-I <br /> Installation will serve: Residence_ Commercial__�__w Otherr- <br /> Number of living units: Number of bedrooms <br /> � Character of soil to a depth of 3-feet:— — -•----� � - -�' - <br /> _ �. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg., ` —_ _Capacity--- • - - -- No.-Gompartments <br /> r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> S LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Size Number <br /> SEEPAGE PITS I Depth <br /> SUMPS ❑ Distance to nearest: well Foundation Property Line <br /> DISPOSAL BONDS ❑ <br /> hereby certify hat l-have prepa�dd this application and that the work will be done in accordance with San Joaquin county ordihances state laws;and' <br /> rules and regulations of the San Joaquin Local Health'District. S <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 su nn er as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cert'ties the followin ertify 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 Calif <br /> t <br /> The applicant for I required inspections. Complete drawing�on r side. Y <br /> E Title: , Date: <br /> i Signed <br /> Q FOR DEPARTMENT USE ONLY l �, <br /> \ Date <br /> t Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Dat ` <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 EI 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, f <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT NO. <br /> INFO C/� a <br /> ♦,EH13-24MEV.i/ntI <br /> EH 1429 <br /> I <br />