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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1801 E. HAZEITON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT,EXPIRES 1'YEAR FROM DATE ISSUED <br /> x '(Complete in Triplicate) <br /> . This <br /> Applicacation is <br /> tion is hereby made to-then5an'Joaquin Local Health Districtfor sewa permit <br /> No 1862 forcwell/dpump and the Rules and all the work IR Regulations of the San l Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 g <br /> Local Health District: < l 4 <br /> i r - !! . <br /> f f City l/Size iL t�- PM R1 <br /> Job Address /� Ze <br /> 11 <br /> Owner's Name <br /> moi/ ^t i <br /> ' cense-N Rhori <br /> Contiacto - —Address <br /> WELL REPLACEMENT ❑' 'i " DESTRUCTION ❑ 'f <br /> TYPE OF WELL/PUMP: NEW WELL :f OTHER ❑ I <br /> PUMP INSTALLATION � SYSTEM REPAIR 1-1 .�- , <br /> DISPOSAL FLD. PROP. LINE i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -AGRICULTURE WELL DTHER WEL-L-- PITS/SUMPS <br /> FOUNDATION ./5—..— f <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT DN pia of Well Casing ' <br /> ❑ Indu pen Bottom ❑ Manteca Dia. of Well Excavation cificatrons <br /> Type <br /> of Casing �Y.� <br /> = omesticlPrivate ❑ Gravel Pack ❑ Tracy1 e of Grout — <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> (`� Public _ - - <br /> I I Irrigation �..Approx. Depth I I E tern ♦Su��e Seal Installed by F <br /> H P /� State Work Done_ <br /> Repair Work Done [S Type of Pump ILi <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material IBelow 50.1 <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIRIADDITIDN [ 1 DESTRUCTION I I av[ailatretrwithin 20system 0 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> F Water table depth <br /> Character of soil to a depth of 3 feet: r No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity _A <br /> '"'"" '�� Method of Disposal <br /> PKG..TREATMENT PLT. ❑ ,. ope <br /> Prrty Line <br /> Distance to nearest: Well Foundation_ - .•. �e <br /> r . <br /> LEACHING LINE ❑ No. & Length of lines <br /> -."�4f iL. '•Tdtal length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Weil Foundation Property tine <br /> i _ <br /> Size _ Number <br /> SEEPAGE PITS I I Depth Property Line <br /> F SUMPS L-1Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> that I have repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify p <br /> ` rules and regulations of the San Joaquin Local Health District. <br /> x. <br /> Home owner or licensed agent's signature certifies the following: "! certify that in the performance of the work for which this permit is issue- <br /> Home <br /> !shall not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> I 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 /> i k <br /> tion laws of California." <br /> k . <br /> The applicant m call far all required <br /> nmplete drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date Z— Area <br /> Application Accepted by . <br /> Date. f Final Inspection W614021-- <br /> Date <br /> Pit or ro Inspection by <br /> Additional Comments: <br /> ElStk 466-6781 11 Lodi 369.3621 ❑ Manteca 823 7104 C3 Tracy 835 6385 <br /> Applicant.- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 # <br /> I <br /> FEE CK RECEIVED BY DATE <br /> ;11M�'NO. <br /> INFO AMOUNT DVE AMOUNT REMIITTED CASH+ EH 53-24{REV.f/Hsl Q pLo <br /> 0 ®� <br /> EH 14-28 y <br />