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} APPLICATION•F,OR,PERMIT '
<br />SAN JOAQUIWLOCAL'.HEALTH DISTRICT
<br />1601 E. HAZEL i ON AVE., STOCKTON, CA
<br />Telephone (209) 466 67.81 u
<br />,i. 3C1 ,t t'•- °,f'+i -t ✓ti r13 f =.� lii;?�,r'
<br />PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED•,,
<br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein'described.> ibis ap> iit?a#ion is
<br />made.in-compliance'with-San Joaquin --County,Ordinance)No: ;549 forsewage or.No:;1862 for well/.pump-and-the Ruies and;Regulations-,of the:San Joaquin
<br />Local Health District
<br />.in � ;? ,•.4i .a�rsii:..4.7�.'� '�i-`�� V,'1� �+,� .;E'7�,atxnv[ �`• +3,' �`� i:`f�4;'.{?� ?t',x i.'�p •''t
<br />.s�3 �., '��S' E�?'Jk'r'+ , �"���{; �� cirj� r7 �i S'r :• �: --: .�ti .� �'(r�'tl �Rf I`'F{�4t'' .w r ,r; %
<br />Job Address
<br />City. .
<br />,Lot $Ize PM
<br />�.. - . .
<br />Owner's Name Address
<br />�_.-__.Oontractor's Name. License No. t Phone
<br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEWT ❑ DESTRUCTION ❑
<br />"PUMP INSTALLATION ❑ +SYSTEM REPAIR ❑ " OTHER ❑ i
<br />.DISTANCE TO,.NEAREST:SEPTIC TANK. I _ . SEWER_ LINES • ' DISPOSAL FLD. PROP. LINE
<br />FOUNDATION AGRICULTURE W1 ELL_ .,OTHER WELL PITSlSUMPS
<br />w INTENDED USE, TYPE OF WELL• PROBLEM AREA CONSTRUCTION SPECIFICATIONS +
<br />-- D Industrial v ❑Open Bottom - -- ❑ Manteca Dia. of Well Excavation Dia. of WA. Casing ,
<br />_ ,❑ Domestic/Private, ❑ Gravel Pack ❑ Tracy t � Type of Casing Specifications
<br />❑Public - ! ❑Other ❑ Delta 4Depth of Grout Seal' t Type of Grout_
<br />f- - :❑ Irrigation f- —L -Approx..: Depth •-- ❑ Eastern fl. Surface Seal Installed by 1
<br />Repair Destruction
<br />truct on e 11 Well Diameter Sealing Material (top State Work Ione d
<br />..Depth ' � Filler Material (Below 50') _ -
<br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION El (No septic system permitted if public sewer is:
<br />v 1 , _ available within 200 feet.)
<br />Installation will serve: ' Residence _ 1 Commercial _ Other
<br />Number, of living units: Number of bedroomss f
<br />T" Character of ,soil to a depth of 3 feet: `f ' r- _F„ Water table depth
<br />$EPilG TANK, ;p iType/Mfg # ! r .. t Capacity No. Compartments
<br />PKG.TREATMENT PLT. ❑ i
<br />Method of Disposal
<br />Distance to nearest:' Wel! -1 Foundation Property Line
<br />LEACHING LINE No & Length of lines tal length/
<br />l ' FILTER BED "Distance to'nsarOSW ' Well Foundation- s� Property Line
<br />YJ 4V
<br />SEEPAGE PITS 'Depth Size " Number
<br />SUMPS " "E❑ 'Distance to nearest ""'"W 7
<br />I
<br />6
<br />l e oundatlon Property Line
<br />I,. =DISPOSAL PONDSi i ❑ ;'j-� i� y,� h r
<br />1 hereby certify; that l have prepared this application and that the work will be done inraccordance with San Joaquin county ordinances, 'state laws, and
<br />rules and regulations of the San -Joaquin Local Health-District..-yw:
<br />Home owner or licensed 'agent's signature_ cer't'ifies'the following: "I certrfy�that m the•perfo�ce of the work for which this permit is issued, I shall not
<br />employ any person in such mariner as to become subiect to workman's compensation -laws of,Californla."- Contractor's hiring or'sub-contracting signature
<br />;certifies the following: "I ber*. thatin-theperformance of the,work for which this perinit•is issued, I shall employ persons subject to workman's compensa
<br />Thea lica California. f all'f wr9dY ~ i W ,
<br />i tion laws of
<br />PP7 coons.. Corm ete wing on side.
<br />�Slgned� Title Dais:
<br />FOR D.EPARTMENTUSE ONLY
<br />'Application Accepted by, Dated
<br />; pe Y i Dete Final In ti
<br />_-
<br />r
<br />Pit or Grout Inspection b � I ��e� , Inspection by ' C Date!!O�
<br />.Additional Comments:
<br />11 Sok •466 6781 -v -- .❑ Lodi 369-3621 - Manteca' -823-7104 r- ❑ ,Tracy 835 6385 l -
<br />'Applicant;- Return all copies to: Environmental Health Permit/ Services' 1601 E. Wazelton Ave., R.O. Box 2009, Stk i CA 95201
<br />+ EH 1344 (REV. 7018.71
<br />a FEE'
<br />INFO`
<br />7AMOUNT DUE '
<br />,AMOUNT REED --
<br />,, MITT
<br />CK
<br />CASH
<br />RECEIVED BY .` ` GATE i-
<br />PERMIT`NO
<br />_,j1
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