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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE'LTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application. This is <br /> aith District for a <br /> rk <br /> Application is hereby made to the San Joaqun d <br /> in ocance No.549 for sewage or permit <br /> No. 1862 forcwell and/or <br /> pump and the Rules and IRegusationds of he San Joaquin <br /># made in compliance with San Joaquin County Or <br />§ Local Health District. .�.. <br />�. Cit1�.dn� Lot size <br /> PM <br /> 15, y , <br /> Job Address <br /> Address <br /> �� 1 � — Phone <br /> I Owner's Name <br /> 1 cense No-2.2 I 3 Phone <br /> Contractor Address <br /> t NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 1-3TYPE OF WI=LL/PUMP: SYSTEM REPAIR 12OTIR ❑ <br /> PUMP INSTALLATION D _ <br /> DISTANCE TO NEAREST: SEPTIC TANK 160 SEWER LINES DISPOSAL FLD. .-- LINE <br /> PROP.ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> I TYPE OF WELL PROBLEM AREA ,,CONSTRUCTION UMPS <br /> SPECIFICATIONS �+ fly <br /> INTENDED USE Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava'on Specifications <br /> ► Gravel Pack Tracy Type of Casing <br /> f Domestic/Private _ Type of Grout <br /> [�-Other Cl Delta Depth of Grout Seal <br /> M Public r ,� <br /> I i IrrigationApprox. Depth 1 1 Eastern Surface Seal Installed by <br /> , __kmS " <br /> Type of Pu �+� H•P State Work Done <br /> Repair Work Done El TYP rm p Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameler I-IS.. -- <br /> Depth Filler Material (Below 50') <br /> \ <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION l HLVAIHIADDITION l i DESTRUCTION I 1 available within ewithin 200 feet.) if public sewer is <br /> Installation will serve: Residence L Commercial. Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3'feet: No. Compartments <br /> ❑ Type/Mfg Capacity <br /> i SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Foundation Property Line <br /> I :I <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED <br /> El -Distance to nearest: Well Foundation <br /> a <br /> Size Number A <br /> SEEPAGE PITS i I Depth Property Line <br /> SUMPS L1 Distance to nearest: Well — Foundation <br /> r 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: "I certify that in the performance of the work for which this permit is issued, I signature <br /> shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." contractor's nslring or subject to workman'scompensa- <br /> certifies the following:­I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The appl ust c I fi�inspe�ctions. omplete drawing on reverse side. <br /> Title: <br /> Date: <br /> Signed�( <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> FiI spection by etc <br /> Pit or u Inspection by Date <br /> a --� <br /> � ra <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi ,..369-3621 [1 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 /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> (NFD <br /> +.E14 t3-24(REV.1/n51 ��� <br /> EH 14-28 <br />