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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209)466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .. <br /> (Complete in Triplicate) <br /> rk <br /> . This <br /> cation is <br /> Application is herer made <br /> QLocal <br /> nH1No 1862 for wellldpump and the R/or install the �s and'R gulations of he San <br /> or Joaquin <br /> made in compliance <br /> wh San Joaqu nGouty ordinance No.549 for sewage <br /> Local Health District. '{ <br /> City <br /> � <br /> k Lot Size PM <br />` Job Addre/ <br />{ F Address Phone O <br /> Owner's Name _ J <br /> Address License No.( Phone <br /> Contractor <br /> WELL REPLACEMENT DESTRUCTION <br /> TYPE OF WELLIPUII NEW WELL ❑ <br /> IDES <br /> OTHER El INSTALLATION ❑ SYSTEM REPAIR Q <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANS SEWER LINES <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> PROBLEM <br /> u` ti <br /> i <br /> INTENDED USE ^ TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 <br /> t Dia. of Well Casing <br /> F Q Industrial ❑ Open Bottom ❑ Manteca M1 - Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/PrivateT ❑ Grave! Pack ,y El Tracy # Yp g Type of Grout <br /> C Other l l Delta, Depth of Grout Seal YP <br /> fl Public, <br /> i I 1 Irrigation _-Approx. Depth -1 1 Eastern a Surlace Seal Installed by <br /> ! Repair Work Done U Type of Pump H.P, State Work Done <br /> :-Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth I Filler Material IBelow 50'I <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIAODITION l 1 DESTRUCTION I i 'aPerm <br /> vo septic systewi hit m feetit�ed if public sewer is <br /> Installation will serve: Residence Commercial " --Other <br /> j ✓'' Number of living units: Number of bedroos <br /> i mWater table depth <br /> Character of soil to a depth of 3 fest: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> r PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line <br /> f LEACHING LINE ❑ No:& Length of lines Total length/size <br /> FILTER BED : 171Distance to nearest: Well Foundation r - Property Line <br /> 42 <br /> SEEPAGE PITS Depth Size <br /> (� N��tnber <br /> SUMPS Distance to nearest: Well Foundation, Property Line <br /> DISPOSAL PONDS ❑ y' <br /> F <br /> ! hereby certify that I have prepared this application aria that the work will be done it 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 /> s to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner a <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 /> The applicants I r ai equire actions. Compl to wing on r verse side. <br /> Signed X U Title: �1�. « Date: r <br /> F DEPARTMENT USE ONLY 1^� <br /> Application Accepted by <br /> � Date ��` J� Area <br /> b patr� <br /> Ft f or Grout Ins ion b Date Final Inspection by <br /> onal Com ants: <br /> ii Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , <br /> s 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Service <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> jAMj0!UNT DUE AMOUNT REMITTED CASH <br /> INFO+E:H 13-24(HEV.I/H 5Yka <br /> EH 14-2a <br />