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APPLICATION FOR PERMIT <br /> SAN JC3AQUIN LOCAL HEALTH DISTRICT JAN E. HAZELTON AVE., STOCKTON, CA <br /> Telepilmnie (209) 466-6781 Sft fit .D0U11 LOCAL <br /> PERMIT EXPfRES 1 YEAR FROM DATE ISSUED HEALTH DISTRICT <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hem descrb*.1Wtoplication Is <br /> made in compliance with San Joaquin County Ordinance No.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Heakh District. <br /> Job Address <br /> ! �f %Cl Lot Size PM <br /> 44 <br /> Owner's Name __�r'j' dreSs �' ., irrr, Phone -� <br /> Contractor's Name &21��oanse No. C+.f"f -14 Z 3 73 Phone "• <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ,INSPOSAL FLD PROP. UNE <br /> _ FOUNDATION _ AG1UdULTURE wett. ` . �4R'W%L-1� Pfr3/SUMIT <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1§105omestic/Private ❑ Gravel Pack ❑ Tracy Typeof Casing- Specifications <br /> ❑ Public 01 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ rn Surface S94 Installed by <br /> Repair Work Done Poe Type of Pump StA- . H.P. j Y State Work Done <br /> Well Destruction © Well Diameter •• Sealing Material(top 50 <br /> Depth Filler Material(Below 50') t1) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted If;;k sewer is <br /> available widtin 20©feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No.Compartments' <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well -Foundation Property Line <br /> LEACHING LINE D No.&Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size . Number <br /> ti <br /> SUMPS Foundation' y Line <br /> --- <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county.,state tgws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or li s signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shaft not <br /> employ any n in such ma as to become subject to workman's compensation laws of California."Contractor`s hiring or sub-contracting <br /> certifies the owing:"1 eertA that in the perforns nce oftl1 for which this permit Is issued,I shell employ persons subject to wof"'� <br /> tion laws California <br /> The aN req ted reverse side. <br /> ON <br /> Signed „ : � Date: - - J5 <br /> FOR DEPARTMENT USE ONLY , <br /> J <br /> Application Accepted byDate Arm <br /> Pit or Grout Inspection by Date Final Inspection by Date_ <br /> Additional Comments: Z AV <br /> ❑ Stk 406.6781 ❑ Lodi 388-3821 ❑NUnteca 823-7104 ❑ Tracy <br /> Applicant-Return all copies to: Environmental Haft Permit/$swim 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 96MI <br /> EAMOUNT DW_ AMOUNT REWp'mD C K RECEIVED BY DATEINFO PI Imo: <br /> +@I 13M IREY.WM) L4.5 <br /> EH W211 <br />