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o 1 ~ \ <br /> APPLICATIONTOR PERMIT � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT'` <br /> ! 1601 E. HAZELTON AVE., STOCKTON, CA <br /> i Telephone (209) 466-6781 <br /> i <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> .. (Complete in Triplicate) <br /> Appicaton ist to <br /> t and/of install the work herein describe . This <br /> cation is <br /> madle n I ompliance weieby rae to the Sn Joaquin ithdSan Joaquin County ordinance No.549 for sewage ealth District for a or tNo 1862 forcwelUpump and the Rules and R gulations of the San'Joaquin <br /> Local Health District. +{ <br /> (contractor <br /> ob Address <br /> City _T0 b1d Lot Size PM <br /> era ,Qr _3 <br /> Address Phone ( ! <br /> r Owner's Name <br /> _.- � 1 Address License No. Phone <br /> TYPE OP WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION-.El <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE <br /> DISTANCE TO NEARS. IC TANK . SEWER LINES DIS,PO�SAL -� PROP. LINE <br /> FOUNDATI AGRICULTURE WELL — T EH R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE CON ACTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom " ❑ Mante Dia. II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> f 1 Public fl Other x ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation pprox. Depth [.1 Eastern Surface Seal Installed by <br /> Repair Work Do Type.of Pump H.P. State Work Done — <br /> Well, ruction EJ Well Diameter Sealing Material (top 50') (� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NIt EW INSTALLATION I 1 REPAIR/ADDITION 1 l DESTRUCTIO tNo septic system permitted if public sewer is <br /> available within 200 feet-) <br /> kµ / <br /> lnstallafion will serve: Residence— Commercial_ Other . <br /> Number of living units. � Number of bedrooms Al. V1 <br /> Character of soil to a depthkof 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ riType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line a! <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line –� – <br /> SEEPAGE PITS I i -Depth Size _ Number <br /> SUMPSw ❑ Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS " ❑ <br /> I 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 DiMrict. <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: "1 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." a <br /> The app7�IZ <br /> all r uired inspections. Complete drawing on reverse side. <br /> ,� l G <br /> ( Signed Title_ _ Date: f <br /> OR RTMENT USE ONLY / <br /> � 1 Areas � <br /> f Application Accepted by Date4� <br /> Pit or Grout Inspection by /fj� Date Final Inspection by Date <br /> Additional Comments: <br /> LlStk 466-6781 ❑ Lodi 369 1 © Manteca 823 7104 ❑ Tracy 835-6385 <br /> i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 <br /> FEEUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO O <br /> ♦.EH 13-24 1 REV.1/9 51 !�;.. �a �♦��L/ } . <br /> EH 14-29 <br />