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r APPLICATION FOR PERMIT 06 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 Joaquin Local Health District fo a permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin o ty Ordinance No. a or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. O <br /> Cit Lot Size R 4 �� a PM <br /> Jab Address y <br /> Ae <br /> Owner's Name 1 Address Phone <br /> K til' //' / i�'r'+L,�1r/ <br /> Contractor dtlress •License No Phone' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> € f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> {; ti <br /> � FOUNDATION AGRICUL RE LL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL`, PROBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> + ❑ Industrial ❑ Open Bottom twafC7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack `^ Tracy Type of Casing Specifications <br /> 4- <br /> Ii Public Cl Otherr CI Delta Depth of Grout Seat Type of Grout _ <br /> I I Irrigation —..Approx.,Depth { I Eastern Surface Seal Installed by <br /> t ' <br /> Repair Work-'Done C7 Type-of?P_ump.�`= H.P. State Work Done <br /> Well Destruction ❑ Well Diameter r M`'w' Sealing Material (top 50') t' <br /> r ' <br /> k < <br /> 'Depth Filler-Material IBefow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTA TION I- REPAIR lADOITION'I:I. DESTR <br /> ZO <br /> I (No septic system permitted if public sewer is available.within 200,-,feet.) <br /> Installation will serve: Residence_ Commercial-____ Other ' ` r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water 6ble depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. C,m Irimen1, <br /> PKG. TREATMENT.PLT. ❑ Method of Disp al ''!s s <br /> .,Distance to nearest: We <br /> Foundation --Property Line <br /> LEACHING LINE ` , ❑ ' No.& Length of lines Toa iengthlsize Lip <br /> } FILTER BED p: Distance to_nearest: Well � ounclation Property Line <br /> SEEPAGE PITS ( rj ['I Depth 2-5 Size Number <br /> SUMPS L] 'Distance to nearest: Well 0 Q -Foundation t Property-Line " <br /> DISPOSAL PONDS D t ` <br /> 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 Dt%trict. , <br /> Home owner or licensed agent'';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." ContreM64hiring or suit-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." — }- 4.� I e <br /> The applicant us� call for al�oquired ins ctions. Complete awing on reverse side. <br /> Signed Title: Amt.�1 01-1- Date: <br /> CaFOE TMENT USE ONLY <br /> ^� <br /> Application Accepted by Date Area <br /> { Pit or Grout Inspection by �. U Data th� Fina-(Inspect ion by t # Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 .., <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.'Box 2009, Stk., CA 95201 ` r <br /> k r <br /> # IF OUNT DUE AMOUNT REMITTED CA H RECEIVE] BY DATE PERMIT'NO. I <br /> .. VV k _ ...✓ �ritEH 1t3-29IREV.1/11-5) - �7 � <br /> EH 4-28 Lde��, - <br />