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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELLTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ,a, <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 /> sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address r E <br /> i Address Phone <br /> n Owner's Name <br /> lyr—7 <br /> Contractor <br /> Address icense N Phoma <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 CONSTRUGTION SPECIFICATIONS Dia of Well Casing ' <br /> _❑ Open Bottom CI Manteca Dia. of Well Excavation <br /> El Industrial "+ Specifications <br /> - Type of Casing <br /> ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Grout <br /> ❑ Publicw r ` [IOther ❑ Delta Depth of Grout Seal <br /> y �pprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation -� , State Work Done <br /> Repair Work Done ❑ Type of Pump H.P. <br /> p , <br /> Well Destruction ❑ Well Diameter Seating Material {top 50') <br /> Depth l Filler Material (Below 501 <br /> f <br /> TYPE—OF—SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION)T(No <br /> ai-lableiw th system <br /> permitted if public sewer is <br /> feet.) <br />' installation will serve: Residence�� Commercial_ Other <br /> Number of living units:f Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet No. Compartments <br /> SEPTIC TANK-S x❑, Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1 r ' <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE' Q No. & Length of lines, property Line <br /> FILTER BED ❑ Distance.to nearest: Well Foundation <br /> fiSize <br /> SEEPAGE PITS ❑ Depth Number�� Property tine <br /> SUMPS ❑ Distance to nearest: Well Foundation <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 /> j 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 /> i 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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." r "� <br /> " The applicant must call for E req 'red ins ctions. Complete drawing on erre side <br /> Signed � <br /> Title: Date• <br /> FOR DEPARTMENT USE ONLY �1 <br /> Date °r tr Area <br /> Application Accepted by <br /> Date <br /> Pit or Grout Inspection by <br /> " bate Final Inspection by <br /> Additional Comments: <br /> 835-6385 <br /> Stk 466-6781 El Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy <br /> 601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> plicant- Return all copies to: En�ironmentai Health Permit/Services 1 <br /> FEE C RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> + lap-73 EH 1}24(REV.I/e 51 <br /> EH 1428 <br />