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APPLICATION FOR PERMIT <br /> R SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> t <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> t <br /> (Complete in Triplicate) <br /> t and/or install the work <br /> n described. T <br /> is <br /> cation is <br /> madeint <br /> nt complitance wiereby th Sanade toJoaqu the n County ordinalncle No.549 for sewage or ealth District for a permit <br /> No. 1862 forcwell//pump and the Rules and iRegulationss of the San`Joaquin <br /> Local Health District. <br /> CityL7��— Lot Size PM <br /> Job Address - <br /> � j <br /> Address/ ! Phone 3 <br /> Owner's NameI <br /> Contractor� ^ <br /> Address& cl-� License No/-( <br /> Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION k2e, SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: _SEPTIC TANK SEWER LINES DISPOSAL FLD.', PROP. LINE <br /> "FOUNDATION AGRICULTURE WELL OTHER WELL l PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications <br /> 1-1�Public ❑ Other r n Delta Depth of Grout Seal Type of Grout . <br /> LApprox. Dept T-T astern Surface Seal Installed by <br /> Repair Work Done [71 Type of Pump +'� H P �;L State Work Rone <br /> Well Destruction 0 Well Diameter Sealing Material Itop 501 <br /> Depth �z Filler Material:I Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available'within 200 feet.I <br /> installation will serve: Residence I—' Commercial _ Other i <br /> Number of living units: Nur1 ber of bedrooms <br /> Character of soil to a depth of 3 feet-.*. '' 1 . Water table depth <br /> SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal ? <br /> Distance,to nearest: Well Foundation Property <br /> Line <br /> LEACHING LINE ❑ No. & Length of lines 1T__ Total length/size <br /> to nearest: Well <br /> Foundation �� � ^Property,Line -F <br /> FILTER HED ❑ Distance <br /> ,f l <br /> SEEPAGE PITS I l Depth `4 3 Size Number I <br /> SUMPS ❑ 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 /> t 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 woik for which this permit is issued, I shall not <br /> employ any person in such manner as io 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." I',' l <br /> ! The applicant ust call for all required inspections. Complete drawing op reverse side. <br /> Signed X �� �zTTtle: Date: 1 � <br /> FOR DEPARTMENT USE ONLY t� <br /> Application Accepted by DateArea �y <br /> Pit or Grout Inspection by Data Final Inspection by Date / <br /> dditional Comments: <br /> IR 5tk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> A licant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> J <br /> FEE AMOU;UE -AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO 7 <br /> + EH 13-24(REV.t/R5) <br /> EH 14-26 <br /> r <br />