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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 /> (Complete in Triplicate) <br /> de to the San Joaquin Local Health District for a pe <br /> Application is hereby ma to construct and/or install the work herein described. This application is <br /> or Na. 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 9!i <br /> Local Health District. <br /> C Lot Size PM i <br /> Job Address J <br /> Owner's Name <br /> � Address <br /> Phone <br /> ' r yk�ok r 4 y7 <br /> Contra t Address <br /> License K <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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 — -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I a o seilabptic ssystem rented if public sewer is <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 fJ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line Q <br /> 3 <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize V1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line l� <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 /> 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> Theapplicant ust all for all re fired ins ctions. Complete drawing on reverse side. `/+ , <br /> Signed X <br /> W. fi4 <br /> Title: _ —t/ Date:V. ' <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date <br /> -- <br /> Pit or Grout Inspection by Date Final Inspection Dat <br /> ' Additional Comments: <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> I <br /> I' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r.EH 13-24(REV.1/"5l . 04c> <br /> EH 14-28 <br />