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P <br /> APPLICATION FOR PERMIT ' <br /> y SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> i <br /> 1601 E. HAZELTON AVE., STOCKTON, CA i <br /> k Telephone (. 09) 466-6781 <br /> ;PERMIT EXPIRES VYEAR FROM DATE'ISSUED <br /> (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.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for.sewage or No. 1862 forw Il/pu p and the Rules and Regulations of the San Joaquin <br /> Local Health District.. '. 5Cf�7 <br /> t �/f <br /> Job Address XP00 9 �� /'�. , `• �� City Lot Size PM . <br /> �. 1 Phone <br /> Owner's Name r""';address <br /> Contractor's Name <br /> License No. ^�Nn " - Phone <br /> TYPE OF WELL/PUMP: VEW WELL [jp/ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIOONN/❑ SYSTEM REPAIR ❑ OTHER ❑ " <br /> DISTANCE TO NEAREST: SEPTIC TANK': SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL CL— PITS/SUMPS <br /> r; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS It <br /> Dia. of Well Casing <br /> ❑^^ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation g <br /> ae6omestic/Private {Gravel Pack Ilef racy Type of Casing Specifications <br /> ❑ Public ❑ Other � ❑ Type Depth of Grout Seal of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done ! <br /> u <br /> Well Destruction ❑ Well Diameter 4 Sealing Material {top 501 II ' <br /> Depth Filler Material iBelow 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 n <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg'l Capacity No. Compartments X <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C <br /> i � <br /> If LEACHING LINE ❑ No. & Len'g'th of lines Total length/size d <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line x} <br /> Et <br /> SEEPAGE PITS ❑ Depth I Size Number <br /> i SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ #f <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 /> 9 <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 /> ii 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 ap ' t must tail for II r red inspections. mpl a dr on avae. ' <br /> Signed i Date: <br /> J FOR DE RTMENT USE ON j3 <br /> Date Area <br /> Application Accepted by r V <br /> Pit or Grout Inspection by Date Final inspection by Date <br /> ` Additional Comments: <br /> k ❑ Stk 46&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 /> I FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> + EH1 <br /> 3-24 IREV.10/831 p <br /> EN 14-28 <br />