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f^ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT E <br /> ` 1601 E. HAZEL T ON AVE., STOCKTON, CA l <br /> �1 0, <br /> Telephone 52091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 3'Z L" r rN (Complete in Triplicate) J <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 foorr sevyage or No. 1862 for well 1pump and the Rules and Regulations of the San Joaquin <br /> Local Health District.(?�4„���� r3 f7� �aFt7 7��+t'� y0�1 : r.,? -- 4�r c7— <br /> Job <br /> 7Job Address '� �/ 1����rX City Lot Size PM . <br /> Owner's Name �<T Address _J t—C c Phone A-de <br /> /21r L� License No. ��� � r� C <br /> Contractor's Name -� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ I} <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ti <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1�, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIPJIS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing C3 Specifications # <br /> ❑ Public ❑ Other ❑ Delta Depth of Grot Type of Grout <br /> � I <br /> ❑ Irrigation —Approx. Depth.} ❑ Eastern Surface Seal Installed by <br /> Repair Work Done El Type of Pump J� H.P. State Work Done 19 <br /> Well Destruction ❑ Well Diameter __ Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑� DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Weil Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> J <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS r ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ - r " <br /> 1 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 District. <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 1r canner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <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 Californi ." <br /> The applicant must al r a .required <br /> ihsp/ecti . Complete drawing on reve de. <br /> Signed <br /> Title: --•1 Date: <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Dated Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> INFO CASH <br /> + EH 1324{REV.10183) <br /> EH 1426 '� <br />