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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HA EL <br /> AVE., STOCKTOIV, CA <br /> -Telephone 4209? 466-6781 , <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED <br /> lComplete in Triplicates ;.. ;, ,•,<. , <br /> he,work <br /> all t <br /> tr <br /> Application is hereby made to the San <br /> nuiOrdinance ance al Health <br /> DDis for sewage or cation is <br /> permit <br /> 1662 for cwell/dpump and the Rales and(Regulations of he Sant Joaquin <br /> made in compliance with San JoaquinCounty <br /> r <br /> Local Health District. « cY <br /> Lat Size PM <br /> City <br /> Job Address <br /> Phone <br /> Owner's Name u'�� �'� 'Address �r w <br /> i �; �. a <br /> License N e P Phon C <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT ❑ DESTRUCTION ❑ - l� <br /> PUMP INSTALLATION FlSYSTEM REPAIR C1OTHER ❑ <br /> � <br /> SEWER LINES �— DISPOSAL FLD. PROP. LINE <br /> I DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ' CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> 1-1Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> pomestic/Private ❑ ❑ Type of Casing <br /> Gravel Pack <br /> Tracy Type of Grout <br /> Y— LC) Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ irrigation 1 Other Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum <br /> pH.P State Work Done <br /> p 4j <br /> Well Destruction ❑' Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION 1] .(No septic system <br /> m rented if public sewer is <br /> Installation will serve: Residence� Commercial, Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: _ -No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> ---------------------- <br /> Total length/size Q <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> ' FILTER BED <br /> ❑ Distance <br /> to nearest: Well Foundation <br /> 1 Number- Q , <br /> � SEEPAGE PITS ❑ Depth - Size µ: _ . ,.. --, C' <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> 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 signature <br /> shall not <br /> s compensation employ certifiesring or sub <br /> the following sulc errttify that n the perforemance of the wok for which this permit tis issued,fI shall employ persons lsubject t workman-contract'scompensa <br /> n. <br /> r as to <br /> tion laws of California." s i <br /> The appfica all require++ pections. Complete drawing on reverse side. <br /> Title: <br /> Signe <br /> -3;i <br /> FOR EPARTMENT USE ONLY r <br /> �.� '. Date <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final 16spection by YUP• Date y� <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 Ll Manteca 823-7104 ❑ Tracy 83`x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK* RECEIVED BY, DATE PERMIT'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO (r <br /> + EH 13-24(REV.1/851 <br /> d EH 14-26 <br />