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- FOR PERMIT <br /> APPLICATIONO <br /> �t4 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 herein described.This application is <br /> �r made in compliance with San JoaquiCounty Ord�? JJSSrp�Mf�se pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �� ((V������,,Jl <br /> Job Address�l Z f�+ �l 1 VCity4Lot Size V//%C�)PM <br /> Owner's Name Eli V 1V 1�14 Address 'S"m d Phone <br /> `7 <br /> Contractor's Name <br /> Loan No. LL Phone <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK AIK,INEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP CIFIJATIfV! ( ^� <br /> ❑ In nal ❑ Ope ottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ravel Pack ❑ Tracy Type of Casing Specifications <br /> ElPublic ❑ Other ElD Depth of Grout Seal Type of Grou 77 <br /> ❑ Irrigation --Approx. Depth &Kastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> d� Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> -� Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within-200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth '� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> �. <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line L <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ . <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 <br /> rules and regulations of the San Joaquin Local Health District. <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 Californi <br /> The applican I f al qui d pe�tions. Complete drawing on raver ide. <br /> Signed Title: PJ Date: <br /> FOR DEPARTMENT USE ONLYCr <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date �a Final Inspection y Date <br /> Additional Comments."----- <br /> ❑ Stk 466-6781 <br /> El 369-3621 171Manteca 823-7404 IO 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 /> FEE INFO AMOUNT <br /> �DUE <br /> . AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO. <br /> + EH13-241REV.10/831 y� {� - �,✓;� IP ITS- <br /> EH 1426 ! i1 <br />