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M L 1 APPLICATION FOR PERMIT ��� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT l <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA ` <br /> Telephone 12091 466-6781 <br /> F PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> . This <br /> cation is <br /> Apple in ioni with a to <br /> oJhe Sanin Gou Qty Ordinalncle No.549 for sewage or ealth District for a permit <br /> No. 1862 forconstruct <br /> e lapump install <br /> nd the Rules and herein <br /> Regulations Of he San f Joaquin <br /> madcompliance <br /> Local Health District. <br /> r PM <br /> j �, City Lot Size <br /> Job Address <br /> 1 f Phone 3 fp <br /> Owner's Name dress <br /> Contractor <br /> Address�A ° `�"�-- License No.,&3_7 3 Phoner <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> OTHER ElPUMP INSTALLATION ❑ SYSTEM REPAIR L4_ <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 Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> T e of Casing Specifications <br /> L�Domestic/Private ❑ Gravel Pack ❑ Tracy YP g Type of Grout <br /> M 1 Public I 1 Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation _Approx. Dept l-I Eastem Surface Seal Installed by — <br /> g <br /> State Work Done <br /> f Pum �1 d..� <br /> H.P. 1 <br /> I Repair Work Done [� Type o p <br /> I Well Destruction ❑ Well Diameter Sealing Material flop 50'I <br /> Depth Filler Material (Below 501 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is a <br /> 4 available within 200 feet.! 74 <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �( <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments !� <br /> PKG. TREATMENT PLT. 1-1 <br /> Method of Disposal <br /> ". Distance to nearest: Well Foundation Property.Line <br /> t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size _ Number <br /> ' SUMPS C1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t 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 shall not . <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's 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 /> l The applicant gtVst call for all requirradinspectioons."Complete drawing on reverse side. Yr <br /> Signed X � it1e: Date: - <br /> f FORD ARTMENT USE ONLY y <br /> --,�- ' <br /> Dat Area <br /> Application Accepted by Q <br /> Pit or Grout Inspection by - Date Final Inspection b <br /> Additional Comments: <br /> ❑ Stk 466-6781 11 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 /> I y �- <br /> p FEEAMOUNT DUE AMOUNT REMITTED CK 4 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> <_:� S `ob <br /> r.EH 13-24(REV.;/!t 51 - <br /> EH 14-26 <br /> r <br />