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a. 1 <br /> E _ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br />'! PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Applicat /or install the work <br /> . This application is <br /> made in I on is compliance wierebyitth Sano)aqu nthe San County Ordinance NoJoaquin Local h.District549 for sewage or permit <br /> No. 1862 forcwell/pump and the Rules and(Regulations of he San l Joaquin <br /> Local Health District. <br /> I /� <br /> i �+ <br /> Job Address �Z��V— Lot Size PM <br /> Owner's Name Address ,!-0/ ., - Phone <br /> j Contractor's Name <br /> License No. r Phon� <br /> TYPE OF WELL/PUMP: N ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 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 /> Cl In nal ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. i f Well Casing <br /> Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Dep1h ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump�,�L Seal State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 50'1 G <br /> Depth Filler Material (Below 501 <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available septic:hit m permitted if public sewer is LA <br /> [ Installation will serve: Residence— Commercial_ Other n <br /> Number of living units: Number of bedrooms 1. <br /> Character of soil to a depth of 3 feet: Water table depth 'S <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 1 PKG. TREATMENT PLT. <br /> 71 Distance <br /> of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line o <br /> I SEEPAGE PITS ❑ Depth Size Number <br /> M 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 /> that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify <br /> employ any person in such manner as to become subject to workman's compensation laws of Cal'rfornia." 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed �� Title ,Date: G <br /> FO DEPARTMENT USE ONLY <br /> ' Date � Area <br /> Application Accepted by <br /> f Pit or Grout Inspection by Date Final Inspection by Date 9'� <br /> h <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT REMITTED C RECEIVED BY DATE PERMIT" <br /> INFO <br /> .} ill-7r2� <br /> EH 13-24 IREV.101831 <br /> 114-28 <br />