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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (2091466-6781 <br /> PER EXPIRES 1 YEAR FROM DATE ISSUED 6 i <br /> (Complete in Triplicate) <br /> s ication is i <br /> rdinance No.549 for sewage or No. 1662 for welllPump and the Rules and Regulations of the San Jpaquin 1 <br /> Application is hereby made to the San JoanuinOLocal Health District for a permit to construct and/or install the work herein described.This a <br /> made in compliance with San Joaquin County <br /> Local Health District. PM <br /> c4ALWot Size <br /> 13 p!% /�>!�� City <br /> a <br /> Job Address <br /> Phone <br /> t Address <br /> Owner's Name Phone <br /> t <br /> Address License No.��� <br /> I Contractor WELL REPIJACEMENT ❑ DESTRUCTION ❑ <br /> lNEW WELL L3 0TH 11- <br /> ( TYPE OF WE SYSTEM REPAIR IJI PUMP INSTALLAT C1SYSTEM <br /> FL PROP. LINE i <br /> EWER LINES �— pITSISUMPS <br /> DISTANCE-TO NEAREST: SEPTIC TANK �1 AG ULTURE WELL OTHE LL— ,i <br /> r FOUNDATION �— <br /> "TYPE OF WELL PROBLEM AREA NSTRUCTIO ECIFICATIONS Dia. of Well Casing <br /> INTENDED USE ❑ {fan— tJ Dia. Excavation <br /> ❑ Open Bottom Specifications <br /> ❑ Industrial ❑ Tracy pe of Ca i 11 <br /> ' ❑ Domestic/Private <br /> ❑ Gravel Pack Type-of Grout <br /> Depth"of.Grout al - - I <br /> p'Delta _F,,,,,..,,.,...- - <br /> ❑ Public ❑ Other " Surface Seal Installe <br /> Jpp <br /> 4rox. Depth ❑ rn: e <br /> ❑ Irrigation p T H.P. <br /> Ste ork Done i { <br /> Type um <br /> Repair Work Done ❑ Yp of P50 <br /> Well 6W eta Sealing Material atop '} ; <br /> Well Destruction ❑ Filler Material (Below 50'} <br /> Depth <br /> I. y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑s REPAIRIADDITION ❑ DESTRUCTION aNailableiwith within f ettted if public sewer,is <br /> ` � <br /> installation will serve: Residence Commercial Other <br /> i � <br /> Number of bedrooms Water table depth <br /> Number of living units: IF <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type IMf9 Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: � Well <br /> Foundation € <br /> s <br /> ITotal.length/size <br /> LEACHING LINE D No. & Length of(Ines' Foundation Property Line <br /> FILTER BED ❑ Distance to nearest: WeN <br /> Size Number <br /> SEEPAGE PITS 17 Depth pro a Line <br /> SUMPS <br /> LI Distance to nearest: Well Foundation p rtY . <br /> DISPOSAL PONDS ❑ ., <br /> l { hereby certify that I have prepared this appatiofi and that the work will be done i accordance with San Joaquin county ordinances, state1laws, and <br /> rules and regulations of the San.Joaquin.Local He District. Apia"Contractolr s hiring or sub contracting signature <br /> licensed agent's signature,certrfies t}ie following: I certify that in the,taws California.,the work for which this permit is tracts g signature not <br /> Home owner or g <br /> employ any person in such manner as to t*come subject to workman's compensation la erions subject to workman's compensa <br /> certifies the following:"I certify that in the performance of th work for which this permit is issued,I shalllemploy p 1 { <br /> ( tion laws of California." <br /> The'a licant mu all for all required inspections. ComQl draing on reverse side. ` t <br /> TO SND { Date: <br /> CL N 'Title: ".:. <br /> Signed ;. <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Date. � <br /> Application Accepted by Date <br /> :. Date� Final Inspection by r <br /> Pit or�Grout Inspection by �, ,,,� .. .- — • <br /> Additional Comments: <br /> 2009, <br /> ❑ Stk 466-6761 ❑ Lodi 3621 ❑ Manteca 823-710x. ❑ Tracyt,83Fr6365 Stk., CA 95201 <br /> Applicant Return all,copies to: Environmentai�Health Permit/Services 1601 E. NazeitoWAVe., P.O. Boz. <br /> CK RECEIVED BY DATE PERMIT"N0. <br /> I'FEE, AMOUNT DUE i AMOUNT REMITTED CASH <br /> INFO' <br /> C.Jv <br /> + EH 1324 TREY.1/0 51 <br /> EH 1428 _ <br />