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41 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 1II <br /> I PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) j <br /> Applicatiorf i he±eby�mad to t�'San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in com fiance wi n aq r Co "Or�ncee Noo.V99 f r se a e or No. 1862.for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District"' /r�.� <br /> Job Address city^ Lot Size PM <br /> Owner's Name Vd lee LQA4" �/ one <br /> Contractor Address f' ! No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT- ❑ !! DESTRUCTION ❑ >' j <br /> PUMP INSTALLATIOWE],!; SYSTEM REPAIR ❑ !i OTHER ❑ I <br /> J <br /> DISTANCE TO'NEAREST: SEPTIC TANK l _ SEWER LINES DISPOSAL FLD. ROP. LINE <br /> FOUNDATION t AGRICULTURE WELL 0TH L PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST SPECIFICATIONS <br /> P , 't; Dia. of Well Casing \ <br /> ❑ Industrial ❑ Open Bottom;, El 1a. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack y Type of Casing a - Specifications k <br /> f l Public ❑ Other f ❑ Delta Depth of Grout Seal I Type of Grout <br /> Irrigation pprox. Depth f I Eastern Surface Seal Installed by <br /> I <br /> Repair Work Done Type of Pump =' H.P. • State Work Done_ <br /> Well Des ton ❑ Well Diameter l Sealing Material (top 50 ' <br /> Depth. Filler Material,(Below 50') r <br /> w. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l 1, DTRUCTION •INoseptic system permitted if public sewer is <br /> available,,within 200 feet.) <br /> }-1 istallation will serve: Residence_ Commercial_ Other <br /> < "Number of living units: Numbedof bedrooms <br /> ..Character of 'soil to a depth of 3 feet: 1 i LWater table depth <br /> SEPTIC TANK'i ❑ Type/Mfg ) p p Ca achy it ! No;; Compartments <br /> + PKG. TREATMENT PLT. Elr 1 ;� Method of Disposal <br /> ref " Distance to nearest: Well -Foundation 11 Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length%size- <br /> FILTER BED ❑ Distance to nearest: Well w Foundation Pro I Line <br /> SEEPAGE PITS I I Depth l Size `F — Number <br /> SUMPS Cl Distance to nearest: Well Foundation ( PropertytLine <br /> DISPOSAL PONDS ❑ <br /> f <br /> I hereby,certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j <br /> rules and regulations of the San Joaquin Local Health District. Jil <br /> Home owner or licensed agent's signature certifies the following: "I 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 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 /> tion laws of California." # r <br /> The applicanjerghst ca0fdr-'a&req in tiogs. late drawing on r si .Signed.X �`�•�" l Title:�����sE`!� '� Date: - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date," U Area <br /> Pit or Grout Inspection - Date Final Inspectiori by 11�46�4 1 Date��� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 95201 <br /> E .FEE AMOUNT DUE AMOUNT REMITTED CK - RECEIVED BY DATE PER IT'NO. <br /> INFO <br /> + EH 13-24 IREV. <br /> EH 14-26 !!/// - ✓✓✓ <br />