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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZEL T ON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />li PERMIT EXPIRES TYEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />oaquin is <br />cation is <br />Application <br />catcomplianceon is heieby <br />with to the <br />San <br />nnCounty Ordinance Nte. 548 for sewage h District for a or �No 1B62 for wellipump and the Rules and Regulations of t to construct and/or install the work herein described. tthe San Joaquin <br />ma <br />Local Health District. <br />L tSie PM <br />a3 o S, Qirr .P�r <br />Job Address City <br />f <br />�— a 7 P Phone <br />Owner's Name '� Address p <br />Ooh T75_ a_6 <br />Contractor Address O� License No. � a;%r _ <br />TYPE OF WELL/PUMP: <br />DISTANCE TO NEAREST <br />INTENDED USE <br />❑ Industrial <br />d Domestic/ Private <br />FI Public <br />I I Irrigation <br />Repair Work Done ❑ <br />Well Destruction <br />TYPE OF SEPTIC WORK <br />PtonA) 4(. 2 <br />�_.___ViiEW WELL fl WELL REPLACEMENT ❑ DESTRUCTION "~K <br />PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ <br />SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />D. Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br />❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br />17Other f] Delta Depth of Grout Seal Type of Grout—_- <br />11 <br />rout —II Approx. Depth t) Eastern Surface Seal Installed by <br />Type of Pump H. P. State Work Done — <br />Well Diameter 2 ►1 Sealing Material [top 50') <br />Depth a f` i Filler Material (Below 50'1 <br />NEW INSTALLATION 17 REPAIRIADDITION LI DESTRUCTION I I (No septic systthinem <br />permitted <br />er it ed if public sewer is <br />availab <br />installation will serve: Residence _ Commercial — Other <br />Number of living units: Number of bedrooms <br />Water table depth <br />Character of soil to a depth of 3 feet: _ <br />Capacity No. Compartments <br />SEPTIC TANK ❑] Type/Mfg <br />PKG. TREATMENT PLT. ©LL <br />I Method of Disposal <br />I� Distance to nearest: Well Foundation Property Line <br />LEACHING LINE ❑! No. &Length of lines <br />FILTER BED ❑ Distance to nearest: <br />r <br />SEEPAGE PITS <br />SUMPS <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 cart that in the performance of the work for which this permit is issued, 4 shall not <br />ion laws of California-" Contractor's hiring or <br />employ any person in such inanner as to become subject to workman's compensat <br />certifies the follow: "I certify at in the performance of the work for which this permit is issued, k shall employ persons subject to workman's compensa- <br />sub contracting signature <br />ing <br />tion laws of r <br />The applicant m st f I re -fired inspections. Complete drawing on.,reverse side. <br />Date: <br />Signed X <br />Title: L6 <br />OR DEPARTMENT USE ONLY ,L <br />Application Accepted by Date Area.:Z <br />Pit or Grout Inspection by <br />Date Final Inspection by Datt;/��°�� <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 />Well <br />Total length/size <br />Foundation Property Line <br />I I' Depth Size <br />L1 Distance to nearest: Well Foundation <br />Number - <br />Property Line <br />N <br />FEE AMOUNT DUE <br />INFO <br />i EK 1324 (REV. <br />EH 14-26 � <br />'AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br />�O[ <br />