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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL+HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA { <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> e work I <br /> uin Local Health District for a permt to construt and/or install th <br /> Application is heieby ma SanoJthe Sn oaquan Courcy Ordinance No.549 for sewage oriNo. 1862 forcwell pump and the Rules and R gulations application of the SanJoaquin <br /> made in compliancawith <br /> Local Health District.. <br /> j� Lot Size 0 G� <br /> Cly` Tn City PM <br /> Job Address <br /> Phone <br /> Owner's Name <br /> Address <br /> � � ) �y���P� License No. Phone <br /> �arlti�cto�1 C�IJ�QP Address + <br /> WELL REPLACEMENT DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WE SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES �-- DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL P1TSISUMPS <br /> INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing �S/7 <br /> I❑ Industrial Q Open Bottom ❑ Manteca Dia. of WellExcavation <br /> Type of Casing Z- Specifications <br /> [X_pomesticlPrivate Gravel Pack ❑ Tracy Type of Grout <br /> f l Public I f Other ❑ Delta Depth of Grout Seal <br /> I I Irrigation —.-Approx. DC11th I I Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump <br /> H P State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 50'1 <br /> Depth <br /> r Filler Material IBelow 561 <br /> TYPE OF SEPTIC WORK: NEW-.INSTALLATION I.I REPAIR/ADDITION 13 DESTRUCTION 1 1 avlailabpticle system <br /> in ermined if public sewer is <br /> 1 f <br /> installation will serve: Residence_ Commercial_ Other <br /> Number of living units: ' Number of bedrooms - Water table depth <br /> Character of soil to a depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , <br /> Distance to nearest: Weil rFoundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> k Property Line <br /> FILTER BED ❑ Distance to nearest: Well f Foundation p Y <br /> SEEPAGE PITS - I i Depth Size F Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> k 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 /> 1 rules and regulations of'the San-Joaquin Local Health Diltrict, <br /> 1 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: '9 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." �" y <br /> f The applicant u cail or all re ui d inspe4g0s. Comple e d ing on verse)�Side. <br /> Title: Date: <br /> Signed <br /> FOR (DEPARTMENT USE ONLY, <br /> 4 r+,,,� .rte <br /> ' Date' Area <br /> Application Accepted by .._r <br /> Pit or Grout Inspection by <br /> Date Final In., by pate <br /> Additional Comments: pwru . <br /> i ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 Cl Tracy 835-6 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95241 <br /> - FEE" t; E!!!!Y DATE PERMIT'NO. <br /> i INFO AMOUNT DUE � ��'AMOUNT REMITTED <br /> ..EH 13"24(REV.I/H 5 <br /> EH 14-28 <br />