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1 APPLICATION FOR PERMIT <br /> ._ SAN JOAQUIN LOCAL HEALTH DISTRICT " " ^ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 `7'T <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -C- kJ r <br /> i (Complete in Triplicate) <br /> kApplication is hereby made to the San'J"oaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br />! made in compliance with San Joa in County O 549 for se go or o. 862 for welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health -ct. <br /> Job Address City Lot Size PM <br /> or <br /> n Addres Phone �t <br /> j <br /> Owner's Name <br /> Contractor '11 Address License No. Phone <br /> TYPE OF WELL/PUMP: :NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE LINES SAL FLO. PROP. LINE <br /> FOUNDATION AGRICU URE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dl . of Well Excavation Dia. of Well Casing <br /> r <br /> ❑ Domestic/Private •❑ Gravel Pack ❑ Tr Typ of Casing Specifications <br /> M Public F1 Other Delta Depth f Grout Seal Type of Grout <br /> I I Irrigation _..Approz. De I I Eastern Surface al Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50 <br /> Depth I Filler Material (Below 50') (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION 1.1 OESTRUCTION (No septic system permitted if public sewer is �J <br /> ' available within 200 feet.( <br /> Installation will serve: Residence �� Commercial_ Other <br /> j Number of living units: Number of bedrooms <br /> Character of soil to a"depth of 3 feet: Water table depth , v <br /> I SEPTIC TANK- ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal (� <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS I I Depth 'I Size Number <br /> SUMPS L1 Distance'i 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 /> 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 /> -manner <br /> employ any person in suchr 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 of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." ; <br /> t The applic must call fo requireIf I d in ions. Complete drawing on reverse side. <br /> rl r ^ <br /> lei <br /> Signed Title: Date-, <br /> Date:" <br /> b R DEPARTMENT USE ONLY <br /> Application Accepted by Date 2_/ Area �` <br /> Pit or Grout Inspection b t Date Final(Inspection by Date <br /> �� <br /> } Additional Comments: Ott `r" ! "6 -77 <br /> ( <br /> ' ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 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 AMOUNT REMITTED CASH ,RECEIVED BY DATE PERMITNO. � <br /> INFO <br /> + EH 13-24(REV.1/n slC.�� <br /> EH 14-26.. / 1. i P r <br /> - Jr^•"rte <br />