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APPLICATION FOR-.PERMIT <br /> SAN JOAQUIN_;LOCALtHEALTH DISTRICT <br /> 1601 E..HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781- <br /> PERMIT EXPIRES 11 YEAR.FROM DATE ISSUED , h + ` <br /> Y-If x ,t.(Complete in Triplicate).,.,. t, .is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made"incompliance with San Joaquin County Ordinance No.549 far sewa9e or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Wealth District. <br /> :1C�cYk wsdl -x03 4E) ., tfw, <br /> Job Address <br /> City Size PM <br /> _« Owners Namet'i <br /> Address i3.. "Y�, i;L-2 <br /> PhoneContractor's Naicense No. kr. <br /> TYPE OF WELL/PUMP: Phone <br /> NEW WELL Q WELL REPLACEM NT InDESTRUCTION p <br /> PUMP INSTALLATION ❑ "k <br /> SYSTEM REPAIR ❑ OTHER Q <br /> "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> a . <br /> INTENDED-USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial- ❑ Open Bottom ❑ Manteca of Well Excavation S <br /> ❑ Domestic/Private 11 Gravel Pack ❑ Tracy T Dia. of Well Casing <br /> ype of Casing Specifications tN" <br /> ❑ Public ❑ Other ❑ Delta­ Depth of Grout Seal ! J <br /> El Irrigation _A TVP$of Grout <br /> pprox. Depth '❑ Eastern Surface Seal Installed by ► .. <br /> Repair Work Done ❑ Type of Pump H.P. State WoDone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) )l <br /> DepthFiller Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if O.Ublic sewer is <br /> ` available within 200 feet.) <br /> Enstailation will serve: Residence Commercial Cher " �' (� <br /> ' € Other <br /> f Number of living units.T Number of bedr'oo } <br /> Character of soil to a depth of 3 feet: r - d �r table depth <br /> f <br /> ' <br /> SEPTIC TANK" ❑ Type/Mfg .mom ' f Wate <br /> CapacityNo. compartments <br /> PKG. TREATMENT PLT:❑ �,,, <br /> �"" Method"of Disposal E <br /> Distance to nearest: Well Foundation' "1 <br /> r i Property Line <br /> t LEACHING LINE No. & Length of linJs ! ar I <br /> Total length/size i <br /> ` 'FILTER"BED Distance to nearest: Well (, Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth iumber <br /> t" " SUMPS 'Distance to neares# "Well _ Foundation �-'PropertyLine <br /> DISPOSAL PONDS Li <br /> I hereby certify that I have prepared this application and that the work will be done in'accordance vi th San*Joaquin counfy o'rdinandes, state laws, and <br /> f rules"and`regulations of the San Joaquin Local Health District. r gZ1I �- , <br /> :Home owner or licensed agent's signature certifies the following: "I certify that in the performancerthe 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 Califomia."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 Aall employ persons subjQ to workman's compensa- <br /> tion'laws,of California. <br /> I <br /> The applicant for all requ' �Ipecfi�ons. C�0:nplo.drawing on rside. � + <br /> (. <br /> Signed ,~ <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> ,'Application Accepted by.4 <br /> Date " a Area <br /> Pit or Grout Inspection by 1 Date JFihal Inspection by <br /> ` Date <br /> I Aitional Comments: ! A ! ¢ <br /> t 3tk -466-6761- — ED-Lodi 369-3621- ❑ Manteca 823-7104 ❑'Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95:201 <br /> r <br /> V INFO'FEE AMOUNT�DUE ,AAOUNTiREM1TTE� CKRECEIVED BYCASH DATE PERMIT"NO. <br /> EH 13-24[REV.10!834 EH 1428 i <br />