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APPLICATION FOR PERMIT <br /> SAN JOAO,UINIOCAL HEALTH DISTRICT <br /> " , 1 1601 E. HAZEL T ON AVE., STOCKTON,'CA <br /> " - `'` '4 Q Telephone (209) 466-6781 <br /> x _ <br /> "-` PERMIT EXPIRES 1°'YEAR FROM DATE iSSUIED <br /> .(Complete in Triplicate} . <br /> Application is hereby made to the,'.San Joaquin Local Health District.for a .4 <br /> made in compliance with San Joaquin County Ordinance N 549 for sewa e r No. 1862 for well/pump and the Rules and R ulations of the Sart JoaquinPermither is <br /> Job Address <br /> - ,... Cifi' ��/�� Lot Size �' <br /> PM <br /> Owner's Name ISJ Address .-ep. toQ - <br /> /� Phone 11/1 —� Q <br /> Contractor / QQ& r ". w <br /> �-�_y�Address <br /> TYPE OF WELL/PUMP: License No. 2611 phone <br /> NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ <br /> PUMP INSTALLATIONid? SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKSOTHER ❑ 1 <br /> EWER LINES <br /> FOUNDATION DISPOSAL FLDFOUNDATIONAGRfCULTURE WELL PROP. LINE i <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOWS _ <br /> Q Industria! ❑ Open Bottom <br /> 11 Manteca <br /> ;lCbomestic/Private [3 Gravel Pack 17? Tracy Dia. of Well Excavation Dia. of Well Casing <br /> T C' �• <br /> ype of CasingSpecifications <br /> Public ❑ Other <br /> 1-1j <br /> Cl❑ Delta Depth of Grout Seal <br /> Approx. Depth El Eastern Type of Grout <br /> ❑ Irrigation — <br /> Surface Seal Installed by I <br /> Repair Work Done ❑ Type of Pumpl] <br /> Well Destruction El Well Diameter — 5 H P State Work Done <br /> Sealing Material {top 50') <br /> Depth" n Filler Mat4ial (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic tem P <br /> ' '." P system permitted if public sewer is <br /> Installation will serve: Residence f available within 200 feet.) { <br /> Comma ial T:t 'Other I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg I k Water table depth <br /> Capacity <br /> —1 TREATMENT PLT. ❑ No Compartments <br /> ��. Method of Disposal <br /> Distance to neo est: W6I1- ---= �, t <br /> Foundation Property{{Line' h <br /> LEACHING LINE <br /> C7 No. $ Length of lines „ 0 <br /> nearest: Well Total length/size t I <br /> ❑ Distance to neai 1,4� <br /> Foundation p�perty Line <br /> FILTER BED <br /> SEEPAGE PITS <br /> ❑ Depth Sizel <br />_ SUMPS ❑ DiNumber <br /> stance to neoirest:: 1" {Nell' Foundation t <br /> DISPOSAL PONDS ❑ *- PiopertyL'me <br /> I hereby certify that i,have prepared this application andltha;,thework will be done in accordance witfiii San;Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local HealtliDistrict: -,.I <br /> Home owner or licensed agent's signature certifies the following: "I ce" manc r ), <br /> employ any person in such manner as to become subject to workman's comtpensat on laws of Califomiahe Coit actor s ich thi opsub sub-contracting signature <br /> t <br /> certifies the following:"i certify that in the performance of the work for which this <br /> ermit <br /> tion laws of California." permit is issued,i shall employ p'rsons subject to workman's compensa- <br /> The applicant f all re inspections. Complete drawing on ve side. <br /> Signed <br /> Title:-1%&Ls-�. ��Z S <br /> Date:: <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedb <br /> Date - a Area 1 <br /> Pit or Grout Inspectio y ! <br /> Date Final Inspection by r`+ Date.243 <br /> f: <br /> Additional Comments: � � - i <br /> LlStk 466-6781 <br /> ❑ Lodi 369-3621 ❑ Manteca 823-7104 1-3 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. !71 <br /> Box 2009, Stk., CA 95201 ' <br /> FEE AtvtOUNT DUE CK <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE <br /> PERMITNO. d <br /> + EH M24 iREV.1/s 51 ; <br /> s <br /> EH 14-28 <br />