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APPLICATION FOR PERMIT L ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT " <br /> 1601 E HAZE T ON AVE, STOCKTON, CA <br /> Telephone (2091466-&76+- q6� - 3 za <br /> 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> lor install the work <br /> Thris application is <br /> madeincompliance with San Joaquin County Ordinance No 549 for sewa�u.uin Local Health District for a permit <br /> 862 for wellldpump and the Rules and herein <br /> R Regulations of he San Joaquin <br /> Local Health District <br /> I <br /> Job Address <br /> 1 _ City Lot Size X .. PM <br /> 1� Phone <br /> W��'1C1�� ciress <br /> Owner s Name <br /> Contractor <br /> �- <br /> Address Z, _ License No _Phone <br /> TYPE OF WELL/PUMP NEW WELL �7 WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION C1 DISPOSAL <br /> REPAIR ❑ OTHER II( L`�1►�" <br /> QISPOSAL FLD PROP LINE <br /> DISTANCE TO NEAREST SEPTIC TANK <br /> EWER LINES —_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial Open Bottom ❑ Manteca Dia of Well Excavation Specifications <br /> ❑ Domestic/Private C1 Gravel Pack U Tracy Type of Casing <br /> ❑ Other <br /> fl Delta Depth of Grout Seal _� Type of Grout <br /> I'1 Public <br /> Approx Depth l 1 Eastein Surface Seal Installed by <br /> I I Irrigation State Work Done <br /> Repair Work Done Ll Type of Pump H P <br /> Well Destruction [3WellWell Diameter g Material ftop 50 1 « <br /> Depth F:Ilei Material f$elow 501 <br /> TYPE OF SEPTIC WORK NEW INSTALLATION t ! REPAIR rADDITION I ! DESTRUCTION I a[varlableseptic <br /> w+thin�00 feet <br /> if pubic sewer is <br /> (y , <br /> Installation will serve Residence_ Commercial — Other ,ter n.• <br /> Number of living units Number of bedrooms V' <br /> Water table depth <br /> Character of sod to a depth of 3 feet No Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal n <br /> PKG TREATMENT PLT ❑ Property Line 1" <br /> Distance to nearest Well Foundation � <br /> Total Length/sue <br /> LEACHING LINE Ll No 8 Length of Imes Property Line <br /> FILTER BED ❑ Distance to nearest Well _ Foundation <br /> _ __ r <br /> l 1 Depth Size �� _ _ Number <br /> SEEPAGE PITS Property Line <br /> SUMPS l I Distance to nearest Well Foundation L <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done to accordance with San Joaquin county ordinances, state laws and <br /> rules and regulations of the San .Joaquin Local Health Di3trict <br /> Home owner or licensed agent s signature certifies the following 1 certify that in the performance of the work for which this permit is issued I shall not <br /> empl6y any manner as to become <br /> s of <br /> signature <br /> art f 4 the followingrson insuch subject compensation <br /> ornia Contractor s <br /> ring <br /> sub <br /> I ceniiy that n the performanceof the wok for wh ch this perm tiif <br /> s issuedI shall employ persons isubt cit to workman is compensa <br /> tion laws of California" <br /> The applica�' rd ins )ns Complete drawingo n gverse si I ��T >;77 <br /> Signed <br /> O"'`r' Titlefv Date r <br /> FOR DEPARTMENT USE ONLY <br /> Date 1Z �+ Area <br /> Application Accepted by <br /> Data Final Inspection by Date <br /> Pit or Grobt Inspectton by v <br /> Additional Comments1 <br /> ❑ Stk 466 6%1 D Lodi 369 3621 ❑ Manteca a23 7104 ❑ Tracy 835-6385 <br /> Applicant - Reiurn all copies to Environmental Health Perrtut/Services 1601 E Hazelton Ave , P O Box 2009, Stk , CA 952dl <br /> FEE K B <br /> AMOUNT DUE AMOUNT REMITTEDY DATE PEAM17 NO <br /> � <br /> INFO �t iRECEIVED <br /> Eli 1324 IREV tieb! (� fl /'Q t+ <br /> EH 14 26 <br />