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APPLICATION FOR PERMIT <br /> SAN"JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6751 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) } <br /> Application is hereby macation is <br /> de to the San Joaquin Local Health D�f r sewage or permit <br /> 1862 for well/pump and the Rules and herein10F install the work described. <br /> of the San!Joaquin <br /> pP <br /> made in compliance with San Joaquin County Ordinance . <br /> Local Health District. <br /> City wLot Size PM <br /> Job Address r <br /> Phone <br /> Address <br /> Owner's Name s <br /> ' Phone ` <br /> License No. <br /> Contractor's NameWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL UOTHER 12 <br /> SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION Cr .�1PROP• LINE <br /> DISPOSAL FLD [1 <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWERLINES" 43 } PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL. -- _,3 OTHER WELL <br /> TYPE OF WELL• PROBLEM AREA, CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE �� /i Dia. of Well Casing <br /> Dia. of,Well Excavation—� f b <br /> ❑ Industrial ❑ Open Bottom L7 Manteca Specifications <br /> ❑:Tracy Type of Caning <br /> �C <br /> Domestic/Private Gravel Pack Type of Grout ,rE <br /> ❑ Public <br /> Other .�Delta Depth of Grout Seal <br /> ❑ Irrigation �pprox. Depth ❑ Eastern Fu ace Seal Installed by <br /> Work Done ❑ Type of Pump " <br /> ct H P State Work Done <br /> Repair W <br /> ar <br /> P <br /> ' I to 50'1 <br /> /terra <br /> Well Destruction ❑ Well Diameter <br /> Sealing M P <br /> Depth Filler Material (Below 50'i <br /> f f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ - DESTRUCTION availableuwithin 200-feet.)ltted i# public sewer is <br /> IC Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal , <br /> PKG. TREATMENT PLT._❑ property Line <br /> Distance to nearest: Well Foundation <br /> S <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of linesproperty Line <br /> FILTER SED <br /> ❑ Distance to nearest: Well foundation <br /> Size Number <br /> SEEPAGE PITS ❑ Depth Foundation Property Line— <br /> i <br /> SUMPS n Distance to nearest: Well <br /> DISPOSAL PONDS ❑ <br /> i d that 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 an " <br /> rules and regulations of the San Joaquin Local Health District. <br /> not <br /> Homed owner ersocn <br /> in such manse gas to become subject rtifies the ltd wogkman's compensation l: "I certify that ih the aewsoof Califormance ornia." Contractor's'hi hiring or sub-cont acts g signature <br /> emp Y Y p <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 /> The applicant must for ll ired in tion ._Complete drawing on reve se side: <br /> Title: .�" Date: <br /> Signed ` <br /> OR DEPARTMENT"USE ONLY <br /> I Date Area <br /> Application Accepted byOle <br /> s ty <br /> Date � � Final inspection by Dat <br />{ <br /> Pit or Grout Inspection by ` <br /> Additional Comments: <br /> 1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> CK, RECEIVED BY DATE PERMIT"NO. <br /> FEE I AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> + EH 13-24(REV.10183) <br /> EH W26 - <br />