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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ' <br /> - -Telephone (209) 466-6781 <br /> PERMIT EXPIRES VYEAR FROM:DATE ISSUED , <br /> - (Complete"in Trlplicate) <br /> tsa 2'Z- .� <br /> Application is hereby made to the San Joaquin Local Health Distract for a permit to construct and/or install the work herein described.,This application is <br /> made in compliance with San Joaquin County Ordinance No.549 fosew�age or No. 1862 for well/pump and the Ryles and flegulations of the aJoaquin { <br /> Local Health District. ; :. . , <br /> { ,. a ' PM­ <br /> x rx f adt no Ci Lot Size <br /> Jab Address � .k "� �nit�t .�f�-.� ,r• -. <br /> ' ec.. ' Phone i <br /> Owner's Name Address <br /> f f � se No�l/5��1'1 Phone <br /> Contractor Address i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " *r <br />— FOUNDATION AGRICULTURE WELL OTHER 1NELL_r�: PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom L3 Manteca Dia. of Well Excavation yr <br /> Type of Casing Specffications <br /> ,Pf <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy ' Type of Grout <br /> erPublic El Other C] Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ Easternurface Seal Installed by s <br /> H P: State ork Done <br /> Repair Work Done .0' Type of Pump .- J <br /> Well Destruction El Well Diameter Sealing Material (top 5D') <br /> Depth Filler Material (Below 50') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ a ailseptic system permitted if public sewer is <br /> a <br /> k <br /> Installation will serve: Residence Commercial Other ; <br /> Number of living units: Number of bedrooms Water table-depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK ❑ Type lMfg Capacity <br /> Method of.-Disposal <br /> PKG. TREATMENT PLT. ❑ ,t estr. <br /> r Distance to near , WellProperty Line, Foundation <br /> � r <br /> r <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest Well — Foundation <br /> ize Number <br /> SEEPAGE PITS ❑ Depth �'':.'. " ° $ `'. ,� - ...k <br /> �,."� Property Lirse- mar' -- <br /> SUMPS _ _ ❑ Distance to nearest:est: Well. <br /> Foundation <br /> `. <br /> " DISPOSAL PONDS ❑ S— T� y <br /> i <br /> „ is application and that the work will�;be done in accordance with San Joaquin county ofdinances, state laws, and <br /> I hereby certify that I have prepared th <br /> rules and regulations of the San Joaquin Local Health District:,: yamL. <br /> Home owner or licensed agent's signature certifies the following: l 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."Contractor's hiring or sub contracting signature <br /> certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa <br /> tion laws of California." '' + <br /> The applicant m st call for al wired inspections. Complete drawing on• rse side. <br /> Title: Date: d' <br /> Signed <br /> FOR DE ARTMENT USE ONLY <br /> Date Area - <br /> f <br /> Application Accepted by Ati <br /> Pit or Grout Inspection by Date <br /> Final on by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3521 ❑ Manteca 823-7104 ❑.Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stil CA 95201 <br /> 1 FEE 1C RECEIVED BY - �;D;ATE PERMIT"NO. , <br /> INFO AMOUNT DUE. AMOVNT REMITTED <br /> C� g e--�37 <br /> + EH 1&24 <br /> (REV. 45 , op <br /> EH 1426 <br />