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APPLICATION FOR PERMIT <br />' SAN JOAQUIN LOCAL•HEALTH DISTRICT <br /> i 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209)466-6781 <br /> i PERMIT EXPIRES 1,Y.EAR FROM,DATE 4ISSUED , K. <br /> a m_ .:. ;: . � b 4v r i, = rel P.41 r,.,:,,. {Complete-in Triplicate! <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. TNs application is <br /> made in cornpliance'with San Joaquin County Ordinance No:-549 for:seWage orNo..1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> f Local Health District <br /> tt�P)fDftJr:ik..' : t '" <br /> Job Address Ci Lot Size PM <br /> Owner's Name �Ca, Address �». - -+- n — _ __ Phone <br /> Contractor's Name License No. �� ���� Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIONY( SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:.SEPTIC.TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL' I OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />` industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation Approx.�Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of-Pump} H.P. State Work Done <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 V! <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 <br /> E PKG. TREATMENT PLT. ❑ Method of Disposal <br /> " Distance to nearest: Well Foundation Property Line <br />€ LEACHING LINE ❑ No. & Length of lines Total length/size <br /> " 'FILTER BED r❑ Distance to nearest: Well Foundation_ Property Line <br /> - <br /> SEEPAGE PITS ❑ Depth ll Size Number <br /> SUMPS "' .0 Distance to nearest: Well foundation Property Line <br /> i DISPOSAL PONDS ❑ + <br /> F- t <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 /> 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 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 must gay for all requir inspections. Complete drawing on reverse side. _ p <br /> Signed i� Title: Date: & <br /> ' FOR DEPARTMENT.USE ONLY <br /> Application Accepted by: s /LLJ Date .2 ~ Area <br /> Pit or Grout Inspection by r' Date Final Inspection by �' Date <br /> ! Additional Comments: ' r <br /> :❑ Stk 466-6781- ' ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 - ❑.Tracy 835-6385 <br /> Applicant',- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ' FEE" <br /> NFO <br /> PAMOUNT DUE AMOUNT REMITTED r ASH RECEIVED BY DATE PERMW NO. <br /> f I <br /> 44r <br /> EH 13-24 fREv.1111631 <br /> EH 1 <br /> 428 iID <br />