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APPLICATION FOR PERMIT J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, <br /> (Complete in Triplicate) <br /> d <br /> Application is hereby <br /> e with to <br /> Joaquin County ordinance No.D549 for sewag or Permit <br /> No. 1862 for well/pump aherein <br /> nd the Rules and R guletions application of the SanJoaquin <br /> made in complianc a <br /> Local Health District.,,: ,, „+'k., :. 7 <br /> . '`0 P,(f WCity Lot Size PM r <br /> Job Address O i <br /> IRAd(es�s f '���'' Phone �� I <br /> Owners Name ' <br /> t � ou; _ License No. ® � Phone <br />` Contractor's Name <br /> CTION ❑ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRU <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION F1 -,. Y. <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES -DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 s <br /> Dia, of Excavation Dia. gf'Nell Casing <br /> ❑ Industrial ❑ Open'wottom'4 ❑ Mante`ds i <br /> T. e of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pao ;dracy ^� yp Type of=Grout ' <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ irrigation ._.f=�Pprox. Depth..--�❑ Eastern—­Surface Seal.Installed by Y 1 ' <br /> H P State Work Done J <br /> Repair Work Done �❑ Type of Pump l D <br /> 50'1l (to <br /> i <br /> terap <br /> Well Destruction �❑ Well Diameter Sealing Ma . <br /> 1 Depth Filler Material (Below 501 <br /> ermm P <br /> o se <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION,❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ alvailabPe'w'tliine'200 feet�t7tif <br /> blic sewer is <br /> Installation.will serve: Residence— Commercial Other 'Number ofliving;units: t Number of bedroomsi'�a Water table depth <br /> Character of:soilto a deptWof 3 feet: No. Compartment <br /> SEPTIC TANK ❑ Type/Mfg', Capacity��- <br /> t . ' Method of Disposal <br /> PKG. TREATMENT PLT. ❑ j I " Property Line <br /> 1 ?Distance�to nearest: Well' Foundation <br /> !' Total len gthlsize <br /> LEACHING LINEt } & Length of lines u _ Pro a Line <br /> s ❑ D'istilnce to nearest f W II rF i Foundation P rty ---., <br /> FILTER BED., rf <br /> SEEPAGE PITS ,611rDep4th <br /> ! Size <br /> SUMPS ElDistdnce,to neaiest: Weil Foundation <br /> 1% Property Line 10 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accoriiance with San Joaquin Jcounty 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: "t certify that in the performance 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 laws,of California." Contractor's hiring csub-contracting signature <br /> i, certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject tb wkman's compensa- <br /> tion laws of California." <br /> The applic call for wired in coons. Complete drawing on reverse side. t <br /> i <br /> ''' �^' Data: <br /> Title: <br /> Signed _ i <br /> F <br /> af' FOR DEPA MENT USE ONLY <br /> l _ Date Area <br /> Application Accepted by ate6 _/ f, <br /> iDate Final inspection by <br /> 9,FI <br /> or Groui Inspection by � <br /> Additional Comments: ` �Y~ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 h{ ❑ PAnt�e 623x7 acy 83�r6385 <br /> u�' <br /> Applicant- Return all copies to: EnviroMnmantaI Health ?a S r icaes 1 1 elton Ave.,Its <br /> P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED Cq$H <br /> RECEIVED BY DATE PERMW'NO.- <br /> INFO <br /> EH 13-24(REV.10183? - <br /> q-H 1428 . <br />