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a <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 /> (Complete in Triplicate) <br /> /or install the work herein <br /> .This application is <br /> Application <br /> ir made <br /> San Joaquin Ordinance No.District549 for sewage permit <br /> No 1862 forcwell/dpump and the Rules and Regulations of he San' <br /> Joaquin Local Health Regulations Joaquin <br /> mad <br /> Local Health District. <br /> r <br /> V/� J— City Lot Size PM <br /> Job Address l <br /> �1�n s�dt- Address �` t+� — Phone <br /> Owner's Name II <br /> Phone <br /> Contractor <br /> r4,a �' �Y4� Address License No. �- L <br /> WELL REPLACEME DESTRUCTION EJ <br /> SYSTEREPAIR ❑ <br /> TYPE OF WELL/PUMP: NEW W OTH5P ❑ <br /> PUMP INSTALLATION !1M <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD.L+� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC T QVS pia. of Well Casin lr <br /> ❑ 1pdustrial pen Bottom ❑ Manteca Dia. of Well Excavati <br /> Type of Casin Specifications <br /> Domestic/Private Gravel Pack ❑ Tracy yp g Type of Grout <br /> ,V-1 El❑ Other ❑ Delta Depth of Grout Seal <br /> yp <br /> rox. Depth Eastern Surface Seal Installed by <br /> ❑ Irrigation ----Approx. State Work Done C <br /> Repair Work Done ❑ Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available septiwi hisystem feet.) if public sewer is n <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> \ LEACHING LINE Ll No. & Length of lines Total length/size <br /> bProperty Line <br /> FILTER BED ElDistance to nearest: Well Foundation <br /> l l SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> \ DISPOSAL PONDS ❑ <br /> is application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared th <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,.l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st II for I -Aui d inspections. Complete drawing an revgKse side. <br /> Signed X <br /> Title: /I Date: <br /> FOR DEPARTMENT USE ONLY ry <br /> Date �`�a � Area <br /> Application Accepted bya } l� <br /> Final Inspection by Date d� <br /> Pit or Grout Inspection by <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ TraI 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH <br /> + EH 13.24 1REV.I/K 51 9(-> <br /> EH 14-26 <br />