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ISL <br /> APPLICATIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 1 Telephone 12091 466-6781 l <br /> 7�11vvl-_ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> • � <br /> (Complete in Triplicate) <br /> 9 <br /> cation is <br /> Application is he+eby made to the San Joa luin total Health District for a pe or permit <br /> 1862 for cwellldpuomp end the Rules and all the work IR Regulations of the San. This l Joaquin t <br /> made in compliance with San Joaquin County Ordinance No.549 for sew g <br /> Local Health District. I <br /> I <br /> �— y� y Lot Size PM <br /> Job Address Cit <br /> Q Address�� Phone <br /> Owner's Nam `` ,/1 a <br /> Contractor <br /> Address 112-F_. /�� �G=-' rCi— License No d Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> PUMP INSTALLATION CJSYSTEM REPAIR Q OTHER 11 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type R DomesticlPrivate ❑ Gravel Pack ❑ Tracy T yp of Casing Type of Grout <br /> f'1 Public F1 Other ,I n Delta Depth of Grout Seal <br /> I 1 Irrigation _..Approxi Depth I I Eastern Surface Seal Installed by <br /> 1 H P _�� State Work Done , <br /> Repair Work Done tC Type of Pump c4� <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 I <br /> Depth 1 Filler Material IBelow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I� DESTRUCTION I 1 (No septic thisystem rented if public sewer is <br /> Installation will serve: Residence <br /> Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feed <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> peri <br /> PKG. TREATMENT PLT. D 1 Method of Disposal <br /> Distance to nearest: Well Foundation Proty Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> 'i <br /> SEEPAGE PITS I I Depth Size _ Number <br /> ` SUMPS L7Distance to nearest. Well Foundation Property Line <br /> f 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 Healfh District. <br /> Home owner or licensed agent's signature certifies the fallowing: "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 becorne subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in performance ofthe`work for which this permit is issued,l shall employ persons subject to workman's compensa <br /> tion laws of California." Y ; <br /> r <br /> The ap st call for all require ct' s. Complete drawing arse side. <br /> Title: Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY / / <br /> ! ^ <br /> Date_ Area <br /> Application Accepted by G y_ <br /> Date Final Inspection b Date �� L7 <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 823-7104 D Tracy 835-6385 <br /> Applicant -Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> E CK RECEIVED BY DATE PERMIT IVO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED' CASH <br /> INFO <br /> r.EH 13-24[REV. e s1 f <br /> EH 14-26 <br />