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APPLICATION Ffi 'ONMIT SCANNED <br /> SAN JOAQUiN LOCAL, HEALTH DISTRICT <br /> ' 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> !,� -Q l` <br /> PERMIT EXPIRES '1 YEAR FROM DATE iSS ED ' t <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> permit to <br /> co made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1982 fo a // 1n Ef tlwork Abed. Th{'s application is <br /> ru <br /> Local Health District. and the R d Regulations of the San Joaquin <br /> Job Address <br /> � City` Lot Size <br /> PM <br /> Owner's Name '*1CdfhC Z Phone <br /> �� <br /> Contractor's Name License No. _ �� <br /> s � Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT)F DESTRUCTION ❑ <br /> PUMP WST;4LLATION)k� ' 'SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 4o— DISPOSAL FLD, * PROP. LINE A14(,&l <br /> FOUNDATION _Ze AGRIQULTURE WELL OTHER WELL —I'l TS/SUMPS Zed <br /> INTENDED USE TYPE OF WELL PROIBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation .Dia. of Well Casing �� O <br /> Domestic/Private Q Gravel Pack ❑ Tracy;: r Type of Casing Specificationso � ,� I <br /> ❑ Public ❑ Other ❑ Delta '. Yr Depth of Grout Seal _ �� T <br /> ype❑ Irrigation ---Approx. Depth ❑ Eastern ', Surf a Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P; State Work Done <br /> Well Destruction ? ❑ WeII Diameter Sealing Material (top 50') jh <br /> Depth 1Filler•Material(Below 50'} I <br /> TYPE OF SEPTIC VYORK: NEW INSTALLATION ❑ REPAIR/"ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r available within 200 feet.}" <br /> installation will sdrve: "Residence— Commercial ' Otber <br /> Number of living nits: K Number of betlrooma T <br /> Character of soil o a depthI r <br /> # <br /> SEPTIC TANK Water table depth' e <br /> ❑ ypf3p /Mfg ... j ` i Capacity No. Compartments " <br /> PKG. TREATMENT PLT, ❑ }; i iMethod of Disposal <br /> Distance to nee Well Foundation P <br /> � roperty Line <br /> LEACHING LINE 1 ❑ No. & en h of lines r <br /> � Total length/size <br /> FILTER BED ❑ Distance to neatest: Well Foundation Property line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAVPONDSi ❑ <br /> I hereby"certffy that;j have prepared this application and'that the work will be done in accordance with San Joaquin county ordinance$, state laws, and <br /> rules and regulationk of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I dertify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person hr such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify tlkrWn the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant must call for all required inspe 'ons. Complete drawing on rave a side. <br /> Signed <br /> Tltle: Date: <br /> 67- FOR DEPARTMENT USE ONLY <br /> Application Accepted by i Date Area <br /> Pit or Grout Inspection by —'Date Final Inspection by Date <br /> Additional Comments: j <br /> C,<Stk 488-8781 ❑ Lodi 369.3821 ❑ Manteca 823-7104 ❑ Tracy 835-63 t <br /> Applicant- Return all copies to: Envfronmental HealthPermft/Servioes 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 96201 <br /> INFO AMOUNT DUE AMOUNT REMITTEDfZE <br /> RECEIVED BY DATE pP.ERMIT'NO. <br /> + FH 13-21(REV.10/0] t7� �-,�3EH1426 OT AV 3-24-Ma 3z <br /> . . -. - <br />