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4 <br /> APPLICATION,FOR PERMIT <br /> j SAN JOAQUIN LOCAL WEALTH DISTRICT <br /> r / 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> ` Telephone (209) 466-6781 <br /> ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) f 0 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin Counrdinan Noe ewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j' `J I <br /> Job Address O +•� � - City ' of Size\5 PM <br /> ? _ <br /> rr Phone �u <br /> Owner's Name <br /> / Address <br /> Contractor's Name t -� 'License No. <br /> / Phone � R 9 •�� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ,.F <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE # \[l <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> TYPE OF WELL PROBLEM AREA CON � <br /> I ED USE T CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation la. of Well Casing <br /> ❑ Domestic/Private ck ❑ Tracy Type of C Specifications <br /> ❑ Public ❑ Other epth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth rn ce Seal Installed by <br /> Repair Work Done ❑ Type of Pu N.P. State Work Done <br /> Well Destruction ❑ iameter Sealing Material {top 501 - <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septiclable system <br /> tem permitted if public sewer is <br /> avaInstallation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of b drooms, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg �r Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> : length/size <br /> LEACHING LINE El No. & Length of lines Total len g ' <br /> i 4 <br /> !I` FILTER BED ' ' ElDistance to nearest: W `y Property Line <br /> SEEPAGE PITS Depth Size umber <br /> SUMPS ❑ Distance to nearest: Well 0 undation Property Line <br /> DISPOSAL PONDS ❑ 1 f <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 /> l rules and regulations of the San Joaquin Local`Health District4 <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 /> I employ any person in such manner asto. <br /> '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 /> tion laws of California." t <br /> The applican must call for all re ired ins p ctions. Complete drawing on reverse side. <br /> k . <br /> r ` i Title: <br /> Date: <br /> .Signed <br /> { FOR DEPARTMENT USE ONLY <br /> Application Accepted by } <br /> r Date Area <br /> Date !2 1 Final Inspection b Date' U <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3621 x ❑•Mariteca' 823.7104 ❑;Tracy 835.6365 1 1 $ <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 t 3 a <br /> 5 5 t T I <br /> FEEAMOUNT DUE AMOUNT REMITTED CAS€H RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t <br /> + EH 124(REV.10!63) <br /> EH 1426 <br />