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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> 601 E. HAZEL I ON AVE., STOCKTON, CA �" Y <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate)I -k��N <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the wi9E '0� Xs application is �} <br /> made in compliance with San Joaquin County Ordinance No.549 for sews a or No. 1862 for well/pump and the Rules an I , .Joaquin o� <br /> Local Health District. q N <br /> % , <br /> Job Address City Lot Size PM <br /> Owner's Name <br /> Address one r <br /> � �/� License No. Phone 9 <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION.W SYSTEM REPAIR ❑ OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial L1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of'Well Casing <br /> ❑ Domestic/Private Q Gravel Pack El.Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seat Type of Grout <br /> ❑ Irrigation --Approx. Depth Surface Seal Installed by �4 <br /> Repair Work Done ❑ Type of Pump H.P.1 State Work DoneI <br /> ' Sealin Material Itop 50'1 <br /> Well Destruction ElWell Diameter 9 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIRIADDITION E3 DESTRUCTION ❑ (No septilable c system <br /> item rmiitted if public sewer is <br /> .1 <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms ' <br /> 4 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance toInearest: Well Foundation Property Line <br /> LEACHING LINE Q No.-&Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance totnearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth j Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> 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 Health District. <br /> "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of 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 m II fo. squired inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FORD PARTMENT USE ONLY <br /> Application Accepted by Date Area p <br /> 1 <br /> I Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> C3 Stk 466-6781 El Lodi 369-3621 nteca 623-7104 ❑ Tracy 835-6385, P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environments Health Permit/Services 1601 E. Hazelton Ave., P. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`'NO. <br /> INFO y <br /> F tt <br /> +EH 1324 IREV.10/83) <br /> EN 14-26 <br />