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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELT0t4 AVE., STOCKTON, CA <br /> Telephone; (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application fm%--an to the San Joaquin Local Wealth District for a permit <br /> No 862 for waionistruct t/ installlor �the work the Rules and(n described.This Regulations of the Sanapplication Joaquin <br /> made in c j""UU n County Ordnce No.543 for sewage orLocal Healt <br /> f P <br /> J City L t Size <br /> Jots Address <br /> Phone r `' <br /> Owner's Name Address +y/�r <br /> Phone <br /> Contractor <br /> dress — License No. <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial Q Open Bottom ❑Manteca Dia- of Well Excavation <br /> L� Gravel Pack C3 Tracy Type of Casing Specifications <br /> ❑ Domestic/Private Type of Grout <br /> F) Public 171 Other 11 Delta Depth of Grout Seal . <br /> f I Irrigation _Approx. Depth i I Eastern Surface Seal Installed by S`^ <br /> Repair Work Bone 0 Type of PUMP H.P. State Work Done <br /> Wen Destruction ❑ Well Diameter Sealing Material flap SW <br /> ixDepth <br /> Fuer Material(below 50') C <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ly REPAIRIADDiTION I I DESTRUCTION I I lNo septic system permitted if public sewer is f\ <br /> available within 200 feet.l �3 <br /> Installation will serve: Residence Other <br /> Number of living units: Number of bedroomes ^, <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Wq Capacity No. Compartments <br /> Disposal <br /> y PKC. TREATMENT PLT.Q Method of pisposai <br /> Distance to nearest: WeIL _ Found ' rt � dy � <br /> IF <br /> LEACHING LINE 0 No. &Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Web Fo ndation Property Line' <br /> Q SEEPAGE PITS l i Depth _7— Si" Number <br /> SUMPS ti Distance to nearest: Well Foundations f .. Property <br /> Line <br /> DISPOSAL PONDS €1 <br /> I hereby certify that I have prepared this applicatiat 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 Datrict. <br /> Home owner or licensed agent's signature oartW*s the following: "I certify that in the performance of the work for wt hich this permit is issued. I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of Califomia." Contractors hiring or sub-contracting signature <br /> certifies the fallowing:"I certify that in the pertontrence 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 applicantt call for required coons. Complete drawing on reverse side. <br /> Signed X , Title: Date: <br /> 2 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r Area <br /> 6or Grout Inspection by Date Final lnspectiansby Data <br /> Additlonal Comments: <br /> U Srk 466-6781 ❑ Lodi 36'13627 O tiMertsacs 823-7144 ❑Tracy <br /> Applicant- Retum all copies to: Environmental health Permit/Services 1641 E. Hazelton Ave., P.O. Sox 2409, Stk., CA 95201 <br /> s <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH RECENEO BY DATE PERMIT'NO. <br /> INFO <br /> EM t3-24[pEv.I?w 5) �♦� C v Z9{ <br /> Ere 14-28 vVV <br />