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I <br /> APPLICATION FOR PERMIT dY J_�:CY. <br />'i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> F. _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> oaquin Local <br /> is <br /> mapApplication is hereby <br /> madeith totheSJoaquin County Ordinancle No.548 for sewage or permit <br /> No. 1862 for cwellipump t and/or install <br /> nd the RRules <br /> l s and rk Ift Regulations of Ithe Sanis t Jcation oaquin <br /> nce <br /> Local Health District. -y <br /> �'J! �'� <br /> GC Lot Siz PM <br /> f Job Address a r <br /> �� Phone <br /> City <br /> v��o <br /> f� 5 <br /> Owner's Name Address <br /> �'f C�(.t s"� r i7 <br /> Contractor <br /> Address License No. Phone_ <br /> TYPE OF WELL/PUMP:. <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> 1 ❑ Domestic lPrivate ❑ Gravel Pack L1 Tracy Type of Casing Specifications <br /> 1-1PublicOther ❑ Delta Depth of Grout Seal Type of Grout — <br /> I i Irrigation _..Approx. Depth l l Eastern Surface Seal !'ristalled by <br /> Repair Work Done ❑ Type of Pump H.P. S_ tate Work Done_ <br /> t v ' Scaling Material (top 50') <br /> Well Destruction ❑ Well Diameter <br /> ! Depth Filler Material (Below 5001) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'! REPAIR/ADDITION i.l DESTRUCTION A(No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> t. <br /> i Installation will server Residence# Commercial_ Other <br /> I Number of living units: Number of bedrooms { <br /> i Character of soil to a depth of 3 feetWater table depth <br /> : <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> PKG. TREATMENT PLT. ❑ r� <br /> i !Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I Property Line. <br /> FILTER BED ❑ Distance to nearest: Well Foundation P y <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> rules and regulations of the San Joaquin Local Health District. I <br /> Home owner or licensed agent's signature certifies the following: '1 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 /> I The applicant must call for ail required ins tions. Complete drawing on reverse side. e <br /> �( Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by t I -Date 3:9 - Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: S <br /> C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835 6385 <br /> i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> O. <br /> FEEWAIMZOUNTPLIE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT ; <br /> INFO <br /> kn <br /> + EH 13-24 IREV.I/R El <br /> EH 14-26 <br />