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lea 'APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 'O 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 /> Application is hereby made to the San <br /> 1Joaquin Local"Health District for a permit to construct and/or install the work herein described. This application is t <br /> or No. 1862 for welllpump and the Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage } <br /> Local Health District. <br /> r? Or,, e,44, City�c k.'{'�r, " Lot Size"too K'I�'1? I M 07 <br /> Job Address CeIrn, I [` -- Phone <br /> Owner's Name . UG �- Address C__q7 � <br /> Sa atc <br /> Contractor �f eif� ��t T`t�– Address���� �f+�� � 3' License No. ���3y� Phone 671–Z;E" <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT Ll D�ESTfiUC710N z <br /> PUMP INSTALLATION ❑ SYSTEM RgPA1R ❑ OTHER ❑ j <br /> SEWER LINES <br /> __ �.,�}��t DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ___N_&_ S ' <br /> FOUNDATION �- AGRICULTURE WELL�J_ OTHER WELL�� PITS/SUMPS �7 ' <br /> INTENDED USE. TYPE OF WELL PROBLEM AREA CONSTRUCTION'SPECIFICATIQNS <br /> ❑ Industrial <br /> 11 Open Bottom <br /> E3 Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> 11 Domestic/Private F1Gravel Pack LlTracy Type of Casing Specifications 1 <br /> T e of Grout , <br /> ❑ Public L3 Other ❑ Delta Depth of Grout Seal YP <br /> I ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Sealing Material (top 50') <br /> Well Destruction ^�, <br /> Well Diameter �>'�-- <br /> Depth Filler Material (Below 50') rdvi <br /> I RK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ o septic system permitted if public sewer is <br /> TYPE SEPTIC WO available within 200 feet.) <br /> L <br /> Installation w erve: Residence Commercial Other <br /> Number of living its: Number of bedrooms <br /> Character of soil to a pth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distan to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. & Length o Total length/size <br /> FILTER BED El Distance to ne st: Well Foundation Property Line <br /> SEEPAGE PITS ❑ -De Size Number <br /> SUMPS istance to nearest: Well Foundation 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: "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:111 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 /> I <br /> ' _ The applica t must 11 for all. wired in pe ions. Complete drawing on reverse side. <br /> A ;Z <br /> Signed <br /> " Title: /���' FriLO 1 1 Dater 7_ tY <br /> P M SE ONLY+ <br /> Application Accepted by <br /> Date Area Ay <br /> — <br /> Date <br /> or Grout In io y <br /> Date Final"Inspection by Date 1 <br /> Additional Co ' nts: *" <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED 6Y DATE. PERMIT'NO. <br /> INFO / <br /> ` +EH 13-24[REV.F/Bbl , [!K <br /> EH 1426 <br />