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APPLICATION FOR PERMIT { <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781. r <br /> I. <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED � <br /> (Complete in Triplicate) <br /> r install the work <br /> . This <br /> cation is <br /> madeinApplication compliance wereby ith Sanade o the Joaqu nn County Ordinalncie No.549 for sewage orealth District for a 't to No. 1862 forcwell/pump and the Rules and(Regulations of the San Joaquin <br /> Local Health District. p <br /> ' } OG Lot Size ` 2 PM <br /> Job Address City <br /> Phone <br /> Owner's Name Address <br /> �d l� t f Address License No. �d 7z� Phon���`j� <br /> Contractor`/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> Q Industrial <br /> LI Bottom C1 Manteca Dia. of Well Excavation g <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy Type of Casing t J <br /> f=1 Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _.Approx Depth I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction Q I Well Diameter Sealing Material (top 50'1, <br /> Depth Filler Material l0elow 501 s <br /> TYPE OF SEPTIC WORK: NEW-,INSTALLATION I ] REPAIRIADDITION W'DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence,. Commercial_ Other 4 <br /> Number of living units: Number of bedrooms :: b <br /> Character of soil to a depth of 3 feet:'_ ' Water table depth <br />{ SEPTIC TANK ❑ Type/Mfg Capacity—L— Nd.' Compartments <br /> PKG. TREATMENT PLT. ❑ N - Method of Disposal <br /> y Distance to nearest: Well T _— Foundation y Property.Line <br /> LEACHING LINE -Q?i� No. & Length of lines M '�Ff Total length/size <br /> FILTER BED L3Distance to nearest: Well Foundation 1 Property Line <br /> SEEPAGE. ti '. %.I/_Depth Size Number <br /> F r Y_ �• 6 <br /> rSUfiMPS4 Ll Distance to nearest: V1leil/G�b/l Foundation �� Property Line <br /> DISPOSAL PONDS ❑ A <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 /> f "I certify that in the performance of the..work for which this permit is issued, I shat!not <br /> Home owner or lice'n'sed agent's signature certifies the following: <br /> employ any person.ii 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 the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all quired inspections. Complete drawing on reverse side. { �1 <br /> Title: Data: <br /> Signed X l <br /> FOR DEPARTMENT USE ONLY ` <br /> Application Accepted byDate ,p'" Area <br /> Pi K or Grout inspection by ate ry Final <br /> Inspection bt Date <br /> Additional Comments: <br /> C1 Stk 466-6781 11 Lodi 369-3621 ❑ Manteca a23-7104 ❑ 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 /> FEE AMOUNT DUE i AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 1324 Ir1EV.1 i A 5Y �(„I■ V V ' '�U ` / LJ' !�(s� r�rJ '/�O� <br /> F EH 14-29 - <br />