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I <br /> APPLICATION FOR PERMIT `S , f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., .STOCKTON, CA <br /> Telephone-(209.)'466-67.81 <br /> PERMIT EXPIRES 7'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work herein describe , This <br /> cation is <br /> Applicaon <br /> with SanoJoaqu nthe SanCoungty ordinaJoauin-Localncle No.549 for sewage or ealth District for a permit <br /> No. 18&2 forcwell/dpump and the Rules and Regulations of the SanlJoaquin <br /> Local Health District. <br /> Job Address <br /> ///G� City of Size PM <br /> y(I <br /> Owner's Name Address Phone\ <br /> i <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLA EMENT F1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing r, <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca.._ -- �J} <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> L'l Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — <br /> k I Irrigation _.-Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 , <br /> Depth Filler Material (Below 50'1 -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I. I DESTRUCTION lNo availaepticle system <br /> ithin 20(1 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: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. © Method of Disposal <br /> Distance 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 Line <br /> 4 SEEPAGE PITS I I Depth Size Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hat the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and t <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, 1 shall not <br /> employ any person in such mariner 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Title: � pate: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted baV/__A Date Area <br /> Pit or Grout Inspection <br /> Date Final Inspection by�a — Date Q� <br /> I <br /> Additional Comments- <br /> ❑ Stk 466-6781 621 ❑ Manteca 823-7104 ❑ Tracy 835-63135 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO A /rxJ� <br /> +.EH 13-24 IREV.1/q 51 �aJ l `�+IA, �� <br /> EH 1429 <br />