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�. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San <br /> o. 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 sewage or N <br /> Local Health District. j' L <br />` ► + City Lot Size PM <br /> Job Address <br /> Phone <br /> A dress <br /> Owner's Name R <br /> censal <br /> Contractor ess RUCTION ❑ <br /> Phone) <br /> e N <br /> TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT 71DEST <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> `% ' PUMP INSTALLATION ❑ PROP. LINE <br /> T ti SEWER LINES DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK` <br /> ! FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMP5 <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> Is ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> r Type of Casing G <br /> ❑ Domestic/Private El Gravel Pack El ' Type of Grout <br /> f 1 Public ❑ Other ------ <br /> 171 Delta µ Depth of Grout Seal <br /> 1. Surfaca Seal Installed by 1J� <br /> I I Irrigation Approx. be I I Eastern , <br /> � `: State Work Dane <br /> Repair Work Done El Type of Puimp H.P. ' <br /> Well Destruction ❑ -Well Diameter _ Sealing Material Itop 50'i y <br /> Depth <br /> ` - Filler Material (Below501 <br /> N I REPAIR/ADDITION i-I DESTRUCTION l I avai6bpe' wit ine200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOted if public sewer is <br /> F j <br /> Installation will serve: Residence Commercial Other�. <br /> Number of living units: � Number of drooms 4 =- <br /> x . I,°E Water table depth <br /> Character of soil to a depth of 3 feet: :.. No;Coirpartmerits <br /> SEPTIC TANK ❑ Type/Mfg a Capacity � <br /> � � Method of Di osal <br /> PKG. TREATMENT PLT. ❑ `` <br /> "w Distance to nearest: Well 1©� Foundation Property Line_- t <br /> {-1 <br /> L LEACHING LINE ❑ No. &:length of fines <br /> .�. Total length/size <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth ° Number <br /> � _ <br /> . UMP � L] Distance to nearest: Well J� — Foundation Property Line <br /> ISPOSAL POND ❑ <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, <br /> rules and regulations of the San Joaquin Local Health District. <br /> following: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agents signature certifies the <br /> compensation laws of California." Contractor's hiring or sub-contracting signatur <br /> employ any person in such manner as to become subject to workman's e= <br /> i in hich this permit is issued, I shall employ persons subject to workman's Compen5a- <br /> certifies the following: -I certify that the performance of the work for w <br /> tion laws of California." <br /> The applicant must c r all r quired i s ci ns. Comple, Ing2 ;,side. <br /> Ili <br /> I Signed <br /> Title: D�" <br /> f FOR DEPARTMENT USE ONLY f <br /> Date <br /> Area <br /> E Application Accepted by <br /> I t Pit or Grout Inspection by <br /> Data Final Inspection by Date <br /> } Additional Comments: <br /> LD Stk 466-6781 ❑ Lodi 369-3621 El 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. CK RECEIVED By DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> r EH 13-21(REV.i i a sr <br /> EH 14-26 <br />