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�. 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 /> all the <br /> .This <br /> cation is <br /> Application is hewith San J aqu n Counquin Local ty ordinancle No.549 for sewage or ealth District for a permit <br /> No. 1662 forcwe lapump and the Ru <br /> workherein <br /> and(Regulations of the San Joaquin `I <br /> made in complianceI <br /> Local Health District. <br /> CeimsTee k Rel City Lot Size 4/t9P--- PM <br /> Job Address <br /> 11,111 I'llOV Phone <br /> Owner's Address <br /> Name `dr �31rJ <br /> Contractor <br /> ,r% ddress14 <br /> / � ��` License No. � � Phone 1 <br /> TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> OTHER ❑ �� <br /> "" PUMP INSTALLATION'❑' 1 SYSTEM ❑ <br /> '�-� SEWER LINES <br /> DISPOSAL FLD. E <br /> —PROP. LIN { <br /> DISTANCE TO NEAREST: SEPTIC TANK pITS15UMP5 <br /> FOUNDATION AGRICULTURE WELL I.2� THER WELL <br /> I INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> Ll Industrial Open Bottom ❑ Manteca Dia. of Well Excavatio^ <br /> Dial of Well Casing <br /> Type of Casing �eL Spelcifications <br /> ❑ Domestic/Private D Gravel Pack ❑ Tracy Type of Grout <br /> FI Public ry l l Other Cl Delta Depth of Grout Seal <br /> S1 <br /> —".Approx. Depth I I Eastern" Surface Seal Installed by !; N <br /> Irrigation State Work Done — <br /> Repair Work Done El Type of Pump H.P. <br /> ± Well Destruction L) Well Diameter Sealing Material )top 50'1 <br /> u <br /> Depth Filler Material (Below 501 �I <br /> DESTRUCTION t <br /> TYPE OF SEPTIC WORK: iNEW INSTALLATION I 1 REPAIR/ADDITION i I i available tlwi hin 200 feet permitted if public sewer is <br /> I Installation wi Residence Commercial— Other <br /> Number of living units: Number of bedrooms < <br /> Wa a depth <br /> Character of soil tcI depth of 3 feet: No. Compartments { <br /> SEPTIC TANK 01 Type/Mfg Capacity j <br /> l Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 1. <br /> Distance to nearest: Well <br /> anon Property Line <br /> i <br /> i <br /> LEACHING LINE ❑� No. & Length of line — tal length/size 0 <br /> ❑ Distance to est: Well Foundation rty Line <br /> FILTER BED i <br /> Number <br /> SEEPAGE PITS z p " <br /> Property Line <br /> SUMPS Cl Distance to nearest: Well Foundation <br /> `rs <br /> , Al <br /> DI5P0 LPONpS I ti <br /> I hereby certify that I have prepared this application and that the work.will W done-in acco dancyjw=th San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Ltical Health D trict. <br /> l Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whicl;this permit is issued, I shall not <br /> employ any persoh in such manner as to become subject to workman's compensation laws of California." Contractor's hi►mg or sub-contracting signature <br /> certifies the followin '):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 - -" °'�M -� <br /> The applicant ust II for all quired inspections. Complete drawing on•reykrs de. /D�a - <br /> Signed X Title: <br /> c Date: . - <br /> r" FOR DEPARTMENT USE ONLY <br /> ' Date �b Area <br /> Application Accepted by _ --T <br /> Final Inspection by Date <br /> Date <br /> Pit or Grout'Inspection'by t <br /> ll,(�r/ <br /> Additional Comments: <br /> LJ Stk 466-6781 ❑ Lodi;369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .eGl <br /> Applicant - Return all copies to:,Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.. C 1 f <br /> qA <br /> CK <br /> FEE 'AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO., <br /> )e <br /> INFO 1 <br /> +.-EH 13-241REV.i/esl r <br /> t EH 14-2$ , <br />