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APPLICATION`FOR PERMIT CA �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZE i ON AVE., STOCKTON, CA f <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1,YEAR FROM DATE ISSUED <br /> k (Complete in Triplicate) <br /> work <br /> . This <br /> Application is hereby made to the San Joaquin Local Health Dig for sewage orrict for a +t to construct No 1862 for well/d/of install the <br /> pump and the Rucation is <br /> l s and+Regulations of he Sant Joaquin <br /> PP <br /> made in compliance with San Joaquin Cbnty Ordinance No. <br /> Local Health DistrictCity <br /> . _ <br /> � 4 <br /> 0 Lot Size �p0 PM <br /> �� `' <br /> Job Address -3 1 9 <br /> Phone <br /> Address o1 !f <br /> Owner's NameALLLI aaj,; <br /> �a + <br /> Address .,� License No. Phone <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: Ni WELL ❑ WELL REPLACEME T ❑ <br /> PUMP INSTAL TION ❑ <br /> SYSTE EPAIR ❑ OTHER ❑ <br /> ' SEWER LIN DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRI URE WELL OTHER WELL <br /> WELL 0 MAREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF. ia. of Well Excavation pepia. of Well Casing <br /> Ll Industrial ❑ On Bottom nteca D <br /> Type of Casing Specifications, <br /> Ll Domestic/Private ❑ Gravel P(ac ❑ Tra Depth of Grout Seal Type of Grout <br /> ❑ Other Cl Delta _ <br /> F1 Public t, Surface Seal Installed by <br />{ I Irrigation --Approx. Depth 1 1 Eastern State Work Done— <br /> f e of Pump H.P. <br /> Repair Work Done ❑ ----- <br /> Type Sealing Material (top 501 <br /> Well Destruction G Well Diameter <br /> Depth t Filler Material (Below 501 <br /> k <br /> TALLATION la REPAIRIADDITIDN t 1 DESTRUCTION thin200 fe <br /> septic eetit �ed if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSavailable <br /> i installation will serve: Residence A" Commefcial f Other i <br /> Number of living units: Number of bedrooms Water table depth <br /> t Character of soil to a depth of 3 feet: No. Compartments <br /> Type/IVI Capacity- <br /> -SEPTIC <br /> apacity.SEPTIC TANK ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation P Y <br /> +4 <br /> Total length/size <br /> LEACHING LINE ❑ No. &.length of lines. PropertyLine <br /> FILTER BED' ❑ Distance to nearest: Well Foundation <br /> I <br /> Size Number <br /> SEEPAGE PITS I I Depth. property Line <br /> SUMPS Ll Distance to nearest: WeII Foundation -- <br /> r DISPOSAL PONDS - ❑ <br /> I hereby certify that I have prepared Ithis 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: "1 certify that in the performance of the-work for which this permit is issued, !shasignature not <br /> ring <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contraca +subiecrt to workman!scompensa- <br /> certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued,1 shall employ persons <br /> tion laws of California." <br /> can Zt�ca�itr lk required inspe ions. Complete drawing on reverse side. <br /> The appli <br /> Title: Date: <br /> Signed X; <br /> I FOR DEPARTMENT USE ONLY <br /> Date — Area <br /> Application Accepted by <br /> , Final lnspectiorl. y Date <br /> �— <br /> Pit or Grout inspection by Date_� <br /> :i f A� <br /> Additional Comments: <br /> ❑ Stk 466-6781. ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> r Applicant- Return all copies to: En ironmental Health Permit/Services 1601,.E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> CK RECEIVED BY DATE f-1 <br /> IT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO. �y ? 73 <br /> ♦ EH 13-24(REV. e s+ - ¢ <br /> EH 14-26 <br />