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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES I'YEAR FROM DATE ISSUED APR <br /> (Complete in Triplicate) <br /> R" E` <br /> Application is hereby made to the San Joaquin <br /> in Local Health District for a permit to construct and/or install the work he;ein,'deg,&q W.ah <br /> "lade in compliance with San Joaquin County Ordinance No. 549 for sewage of No. 1862 for well/pump and the Rules and 6`fsHe hcis <br /> &s.VAq6&in <br /> Local Health District, <br /> Job Address/.7- '7_1 City Lot Size PM <br /> Owner's Name 0 Add(es LA, % Phon:7� 171- <br /> Contracto Address& License No.Lo- Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT 13 DESTRUCTION D <br /> PUMP INSTALLATION A;1 SYSTEM REPAIR 0 OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL — OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Ll Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [?Domestic/Private ID Gravel Pack L) Tracy Type of Casing # Specifications <br /> n Other 17 Delia Depth of Grout Seal Type of Grout—.--- <br /> n Public <br /> I efrigation _,Approx. Dep I I Eastern Surface Seal.Installed by <br /> V I I e - 11-I State Work Done <br /> Repair Work Done n Type of Pump H.P. <br /> Vyeil-bestruction El Well Diameter Sealing Material (top 50'.1 <br /> Depth Filler Material (Below 50"1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAiR/ADDITION ( I DESTRUCTION II (No septic`system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: —water table depth <br /> SEPTIC TANK 0�Typ'ffl4mfg�. 4aR@city No. Compartments <br /> PKG, TREATMENT PLT. C1 Methlod of <br /> Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 1 <br /> I <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation— Property Li I ne <br /> DISPOSAL PONDS El ! <br /> I hereby certify that I have prepared this application and that the Work will be done in"accordan 1ce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local-Health-Drstrict: <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: "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 applicant st call for all r wired ns Complete drawing on reverse side. Date; <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A4Z Date 19-1/ Area <br /> 4V <br /> Pit or Grout Inspection by Date— Final inspection by Date <br /> Additional Comments: <br /> El Stk 466-6781 ID Lodi 369.3621 D Manteca 823-7104 0 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 /> FEECK PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE <br /> + EH 13-24 MEV. H 5) <br /> EH 14-26 <br />