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APPLICATION FOR PERMIT x <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA ° <br /> Telephone {209) 466-6781 i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br /> IComplete in Triplicate} 4 <br /> ll the work <br /> .This <br /> cation is <br /> Application is hereby w th San J he San Jo n,Coun w Ordinance No.District Local Health 549 for Permit No. 1862 for well//pump and he Rules and herein <br /> atio�of the San"Joaquin <br /> made in compliance � sewage I <br /> Local Health District. <br /> r <br /> �'� Ld City Lot Size PM <br /> Jab Address _ <br /> Uf Address Phone <br /> Owner's Name — r <br /> Contractor.. <br /> Address X-2 - License No._ � Phone k <br /> TYPE OF WELL/PUMP NEW WELL WELL REPLACEMENT ❑ DESTRUCTION EJ I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing k <br /> ❑ Industrial Specifications <br /> Domestic/Private, Gravel Pack El Tracy Type of Casing <br /> El Public ❑ Other E3Delta Depth of Grout Seal Type of Gr <br /> Irrigation ---4pprox: Depth ❑ Eastern Surface Seal Installed by <br /> of Pump H.P. State Work Done <br /> Repair Work Done ❑ Type �" I <br /> Well Destruction C1 Wei <br /> Depth I Diameter Sealing Material {top 50'1 <br />` 1Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION ElDESTRUCTION ❑ availablelwih ne200 feet.)permittif public sewer is <br /> e <br /> ' Installation will serve: Residence; Commercial_ Other , <br /> It' <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ElType/Mfg r <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ _ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED PDistance to nearest: Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 'Distance to nearest: Well Foundation ter' Property Line T <br /> C.1._ <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: "1 cortify that in the performance of the work for which this permit is issued, I shall not <br /> employ any perbon 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 mu call for all required ' pections. Complete drawing on r er side w <br /> Signed <br /> Title: Date: <br /> 1 OR DEPA MENT USE ONLY "n " <br /> I Area <br /> Date <br /> Application Accepted by ��-- <br /> I Pit or Grout Inspection by <br /> Date Final Inspection �1'� Date <br /> " rJ� k,v o ; G-�-1 DYl 4 <br /> j Additional Comments. <br /> ❑ Stk 466 6781 ❑ Lodi 369 362 Manteca 823-7104 ❑ Tracy 835-6385 GQar� of f�fro1� • <br /> I Applicant Return all copies to: Environmental th Permitl5ervices 1601 E. Hazelton Ave., P.O. Box 2009, Stk. A 95201 H <br /> !ErHIr GASHRECEIVED BY DATE PERMIT'NO. <br /> b + EH 1324 IREV.1/e 5) <br /> EH 14-26 <br />