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9 * APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR.FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> plication is <br /> Application is hereby made to the San Joaquin Local Health District for a sera pe or it to 1662 for and/or install and the Rules and the work in describeds of his p Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 9 <br /> Local Health District. <br /> rJ15 City Lot Size j PM <br /> Job Address of � 1� (f <br /> t `�� t 1Phone,3f r <br /> Owner's Name Address �j <br /> ^ o.ddress License N <br /> Z-Z& Phone <br /> Contract <br /> TYPE OF WELLIPUMP: NEW WELL CO WELL.REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> r <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 4 <br /> CD Industrial ❑ Open Bottom Ll Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> T e of Casin Specifications <br /> ❑ Domestic/Private Q Gravel Pack ❑ Tracy YV g <br /> t rl Public F1 Other ❑ Delta -Depth of Grout Seal, Type of Grout <br /> i 1 Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H p State Work Done— <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material IBelow 50'] <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I (Noavaseptic <br /> systein 200 feetlt)ed if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: _Z_ Number of b r oms <br /> lWater table depth <br /> Character of soil to a depth of 3 feet: , <br /> SEPTIC TANK Type/Mfg Capacity No. Comport ents <br /> 42 <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Q r <br /> Distance to nearest: Well L Foundation—1/0 Property Line <br /> I th -- Totallengthlsize X� <br /> LEACHING LINE No. <br /> Length.of lines 0 7 z <br /> FILTER BED ❑ Distance to nearest:- WeN Foundation .y4a-- Property Line — <br /> { LI Size ,� N ber� T --. <br /> > SEEPAGE PITS Depth z , <br /> SUMPS ❑ Distance to nearest: Well� �- -Foundatiori__ - "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 67dinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict."v <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 /> uch manneras to becom subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following: ucertify-heft in the pert6rmance of the work for•which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tRa <br /> tion laws of California." <br /> ! The applicant must cal r all requ-e i pections. Complete drawi4g on reverse si <br /> Signed X <br /> Title: Date:69 <br /> I � FOR DEPARTMENT USE ONLY <br /> Application Accepted by - <br /> Date Area <br /> r' <br /> or Grout Inspection -- - pate Final Inspection by Data <br /> �t b <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Menteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK i <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> y,EH 13-24(REV.t'/A51 ;� - 4�`b1 <br /> EH 14-29 <br />