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+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> - Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> /or install the <br /> rk <br /> n describe . This applct,11011 <br /> Application is hereby madeSanoJoa u nnCoungty Ordinance No.549 for sewage or ui.n Local Health District for a permit <br /> No. 1862 for cweii/dpump and the Ruck s and IR gulations of he Sanl Joaquin <br /> made in compliance with q <br /> Local Health District. 1 <br /> � y A City Lot Size <br /> PM -- <br /> Job Address <br /> 13� , , <br /> tress Phone <br /> Owner`s Name � <br /> Contractor !' ddress <br /> License No��•y��, —Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 9 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS { <br /> INTENDED USE TYPE OF WELL PROBLEM AREA` CONSTRUCTION SPECIFICATIONS Dia of Well Casing i 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ! <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ,,` Cl Delta Depth of Grout Seal Type of Grout <br /> I"] Public S_l Other <br /> 3 <br /> astern Surface Seal Installed by <br /> k i I Irrigation --Approx., Dept t i E <br /> P. % State Work Done <br />` Repair Work Done � Type of Pump H J <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50`1 <br /> Depth + .� ��= �` ,'Fide s,Material IBelow_50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION t 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms r, <br /> Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK , ❑ Ty"/M19 t i <br /> ` <br /> Method of Disposal <br /> Pict. TREATMENT PLT. ❑ ` <br /> Distance to nearest: Well Foundation �� f Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation l "' Property tine <br /> y ; <br /> i SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl DistancO'to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ I <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 pe ormance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation`tews-of•California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that inE 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 st c for all re irei9 inspecti s. Complete drawing n`averse side <br /> ills: f t "� Date: <br /> Signed X <br /> f FOR DEPARTMENT USE ONLY ' <br /> r, .i ' Date ���� _ Area <br /> Application Accepted by w <br /> 4Date Final Inspection by Data <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> l ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> t Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEWMOUNTnb.LJE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13241REV.iiHsr 1 <br /> EK 14-26 <br />