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;j <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �I (Complete in Triplicate) <br /> 'San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the <br /> or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. I' <br /> / 2 City <br /> Loi Size Z4//r"'7 / PM <br /> Job Address <br /> i� Address Phone <br /> Owner's Name <br /> I. <br /> Contractor <br /> c Address License IVo. az Phone l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ STRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> ISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO RUCTION SPECIFICATIONS pia. of Well Casing I <br /> Cl Industria! L1 Open Bottom ❑ Manteca ia. of Well Excavation <br /> T e of CasingSpecifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP Type of Grout �- <br /> f-1 Public ❑ Other ❑ Delt Depth of Grout Seal <br /> E I Irrigation Approx. Depth I ! stern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Weil:'Diameter Sealing Material (top 50'1 <br /> Depth Filler Material IBelo 50'I <br /> TYPE OF SEPTIC WORK: INSTALLATION !1 REPAIRIADDITION DESTRUCTION I I availabeINo tlwithin 200 feetstem .) it public sewer is <br /> I! } <br /> Installation will serve: Residence L Commercial_ Other _ <br /> Number of living units: I Number of bedrooms <br /> I 170 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No, Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ �I <br /> iDistance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation . Property tine <br /> er 1 <br /> SEEPAGE PITS i I Depth +{ .S ��-Size 2 Numb � <br /> SUMPS stance to nearest: Well iSd — Foundation 4 0 � Property Line � <br /> DISPOSAL PONDS ❑ <br /> t I hereby certify that I have prepared this appliedtion 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 /> + "I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to became 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:" <br /> The applicant must call f all required inspec' ns. Complete drawing on reverse side. <br /> 1 <br /> Signed X Title: Date: <br /> it FOR DEPARTMENT USE ONLY <br /> ,.. Area -`� <br /> � Appli tion Accepted by Date-� <br /> �11 <br /> Date <br /> _ r ,out <br /> spection by e� — Final inspection by <br /> Additional Comments: <br /> i ❑ 5tk 466 fi781 ❑ Lodi 369 3621 ❑ Manteca 823-7 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/,Se Ices_1601,E. Hazelton Ave_P.O..Box 2009, Stk.,-CA 95201 <br /> E <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY PERMITNO. <br /> INFOrr//'��� �;DA�:TE� <br /> £H13-241REV.tiH51 -70 ,d0 V <br /> EH 14-2e <br />