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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` <br /> 1601 E. HAZELTON AVE., STOCKTON, CA4tf a �gR <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRCMENTAL HEALTH <br /> (Complete in Triplicate) FERPMWSERVICES <br /> all the work herein <br /> . This <br /> cation is <br /> Application is hereby ncewith <br /> to the <br /> Joaquin nCou Qty ordinauln nce No. 549 for sewage or ealth District for a permit <br /> No. 1862 forcwellldpump atnd the Runes and Regulations of he San'Joaquin <br /> made in compliance <br /> Local Health District. <br /> r PM <br /> 's <br /> QJI�trQ� City Lot Size <br /> j Joh Address � <br /> i a ! Sone <br /> Owner's Name Address <br /> C,. Zf� <br /> Contracto�� '� - <br /> Address Q License No.� �� Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION E7 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> T Qmastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'l Public <br /> I� Other r i Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx. Depth t I Eastern iSurface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump.�� H.P. State Work Done C� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION l 1 DESTRUCTION I I (No septic system <br /> in permitted if public sewer is <br /> Installation will serve: Residence 4 Commercial— Other \S <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth (b <br /> SEPTIC TANK E] Type4g Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> e <br /> Distancto nearest: Well Foundation Property Line <br /> I 1 C \� <br /> LEACHING LINE Ll No. & Length of lines Total length/size u <br /> FILTER BED C3 Distance to nearest: Well F Foundation Property Line <br /> Number <br /> SEEPAGE PITS I'] Depth I Size yLine <br /> t SUMPS Ll Distance to nearest: Well. Foundation ` Property <br /> DISPOSAL PONDS ❑ J' <br /> I hereby certify that I have prepared this application and that the work will ba.do a in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. d <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: "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 mu t all for all regr�rons.ed inspections. Complete drawing on reverse side. <br /> E. � <br /> Signed „� Title: IF Date: <br /> F DEPT ENT USE ONLY <br /> �' Date2 Ar a <br /> Application Accepted by <br /> EPit or Grout Inspection by Date Final inspection by Date/yy1/ice <br /> Additional Comments: <br /> f ❑ 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.D. Box 2009, Stk., CA 95201 <br /> .. <br /> _4_ <br /> FEE AMOUNT DUE jAM0U:ENT;REME1 ] SH.d .+ REGEIVED BY DATE PERMITNO.1NF0r EH 13-244REV.I 57 VQ <br /> EH 14-2a <br />