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1 4, t <br /> ,", APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .� 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> z. t } <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> I[ e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewag <br /> Local Health District. <br /> �� City Orlk>��`-Lot Size'' — PM <br /> Job Address ' <br /> ' <br /> Address �r' Phone65�y 16 <br /> f� Owner's Name " <br /> fPhone <br /> Contractor � Address License Na. <br /> YPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C3OTHER ❑ <br /> r <br /> DISTANCE EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> UNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF Dia. of Well Casing <br /> t ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation <br /> Specifications <br /> ❑ Domestic/Private ❑'Gravel Pack ❑ Tracy yp sing SpecType of Grout <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout e <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H p State Work Done <br /> Repair Work Done [3 Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') �f <br /> i Depth Filler Material (Below 50'i (�1J <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ n DESTRUCTION ;vailabpe� within 200 feettted if public sewer is 4 <br /> + Installation will serve: Residence Commercial f Other # <br /> Number of living units: Number of bedrooms-' <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ❑" Type/Mfg Capacity No. Compartments t <br /> SEPTIC TANK <br /> i].. <br /> Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines <br /> { Total length/size <br /> FILTER BED ❑, Distance to nearest: Well Foundation ..a Property Line <br /> Number <br /> SEEPAGE PITS ❑ Depth Size <br /> l SUMPS ❑ Distance to nearest: Well Foundation f Property Line <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 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."Contractors hiring orc 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 compenSe <br /> tion laws of California." - <br /> The applica st call for all re uired inspections. Complete drawing on reverse side. <br /> Title: w Date: <br /> �5igned - <br /> FOR DEPARTMENT USE ONLY '� O� <br /> Date 14- Area <br /> Application Accepted by <br /> Pit or Grout Inspectio <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 6354M5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r PEE C RECEIVED SY DATE jPERMITt NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED 5 <br /> +EH 13-241REV.I/As) <br /> �� <br /> d <br /> EH 1428 <br />