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APPLICATION FOR PERMIT G <br /> } SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ 1601 E. HAZELiON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> /or install the work <br /> . This <br /> cation is <br /> Application is lance with <br /> SanoJoaquin San Counguin Local Health District for a pty Ordinance No. 549 for sewage or INo 1862 fort to cwellldpump and the Rules and herein <br /> Regulations of of the Sanl Joaquin <br /> made in compliance with S <br /> Local Health District. <br /> } PM <br /> Job Address <br /> 3 City C Lot Size <br /> Phone <br /> �. Owner's Name s. <br /> +� <br /> Address <br /> Contractor License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL FIWELL REPLACEMENT 1:1DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES-" DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> Go <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial n:Open Bottom ❑ Manteca Dia. of Well Excavation <br /> r <br /> Type of Casing <br /> Specifications — <br /> O Domestic I Private 0 Gravel Pack ❑ Tracy YP g Type of Grout <br /> I'1 Public L] Other ❑ Delta Depth of Grout Seal <br /> 1 Irrigation Approx. Depth 1 Eastern Surface Seal Installed by <br /> . H P State Work Done <br /> i Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑, Weil Diameter Sealing Material (top 50') <br /> j Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION l (NailabPe'witys <br /> hin 200 feetLrm.) if public sewer is <br /> Installation will serve: Residence+ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> t Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property'Lin6"" E <br /> I � � I <br /> LEACHING LINE ❑ No. Length of lines Total length/'size M <br /> r 3 <br /> i FILTER BED 171 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth I Size Number <br /> i <br /> SUMPS Ll Distancre to nearest: Well. _Foundation._ Property Line <br /> DISPOSAL PONDS ❑ .r <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 taws of California." Cantracecsonslsua suring bject to warkmant'scompensa- <br /> signature <br /> certifies the following: "I certify that i;the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The ap lican must call for all requiied spections. Complete drawing on reverse side. <br /> F t Title: l� I 'fi/ -- ��_ <br /> { Signed,X - <br /> �!- �� <br /> FOR DEPARTMENT USE ONLY <br /> I I Date '� Area <br /> Application Accepted by r q <br /> k Pit or Grout Inspection by <br /> Date Final Inspection by ��"�`*��`-� Date Z O <br /> :t Q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71114 ❑ 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 /> L <br /> FEE AMOUNT DUE AMOUNT REMITTED Ic# RE ED BY DATE PERMIT NO. <br /> j <br /> INFO SH <br /> -21 E:44 <br /> ..EH 13-24(REV. /e5) <br /> EH 14-26 <br />