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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 4 1601 E. HAZELTON AVE., STOCKTON, CA �� t <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED Ir;� <br /> (Complete in Triplicate) - X,3 1 <br /> Application is hereby made to the San Joaquin Local Health District for'a <br /> permit to construct and/or install the wok herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for se <br /> ` Local Health District. wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> F <br /> Job Address <br /> (� ity Lot Size PM <br /> _ Owner's Name J <br /> Address <br /> Phone V U G b <br /> ContracEor .:1✓/Z51 til/� ess <br /> License No. J '� p" hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ' PUMP INSTALLATI L375YSTEM REPAIR Q <br /> DISTANCE:TO NEAREST: SEPTIC TANK �i .11 *++ OTHER ❑ <br /> SEWER LINES 1 0A FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE L "OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR08LE REA STRUCTION=SPECIFICATIONS= <br /> ❑ Industrial ❑ Open Bottom ant Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Dia. of Well Casing <br /> ❑ Public ❑ Other; Y pe of Casing R Specifications <br /> Delta Dep of Grout Seal <br /> ❑ Irrigatio n Type of Grout_ <br /> �Approx. pth ❑ Eastern Surface I Installed by <br /> Repair Work Done ❑ Type of mp r. H.P. 1. I <br /> State Work Done F i <br /> Well Destruction O�•We -Diameter --- Sealing Material (top 501)1-w 1W 14 <br /> I <br /> Depth I Filler Material {Below 501} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTI N ❑ ( se tic s stem <br /> /� P Y perrriitted•if public sewer is <br /> Instapatio 11 will serve: Residence.+. JfI/ �ilable within 20j0 feet.► r <br /> Commercial_ Other , <br /> Number of living units: <br /> r N her of bedrooms <br /> of soil to a d <br /> Character of 3 feet: '4 <br /> SEPTIC TANK r aideptf5 I <br /> ❑ Type/Mfg Capacity No. Comparhnants j <br /> PKG. TREATMEN-VOLT. ❑ <br /> Method of petty LiDisposal <br /> Distance to nearest: Well Foundation I i <br /> Line <br /> LEACHING LINE ❑ No. & Length of lines r <br /> Total length/size""�'�""'r � <br /> FILTER BED G,/ ❑ Distance to nearest: r Foundation <br /> Property Line <br /> SEEPAGE PITS r <br /> ❑ D Size Number I <br /> SUMPS Distance to.nearest:. WeII Foundation t"a <br /> �- .,..... ,.. Propert�rt�ihe" <br /> DISPOSAL PONDS FED] "� 1 i <br /> I hereby certify that I have prepared this application and that the workl`!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 �� 1 <br /> employ any'person in such manner as to become subject to wo kman's"rwmMfV tpensation laws of California." Cont actowork for r'slh ringch s or sub-cont actrmit is ingl signature kt <br /> hat in the performance <br /> certifies the,following:"I certify that in the performance of the work for-which this <br /> tion laws of California." permit is issued,I shall,employ persons subject to workman's compensa- <br /> The applicaA must callf r 11 requir inspections. Complete drawing on reverse side <br /> r a <br /> Signed 1 � , <br /> Title: a - Date: <br /> MEPATMENT USE ON Y ��YApplication Accepted by .,�A Date Area V 1 <br /> Pit or Grout inspection by <br /> d Date Final Inspection by Date ? <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-36'11 ❑ Manteca 823-7104 ❑ Tracy 83�r6385 trt 7 <br /> Applicant-;Return all oopies•to:-Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> * FEEAMOUNT <br /> INFO­ <br /> NFO -- <br /> DUE AMOUNT REMITTED ,. CASH - RECEIVED BY, .. DATE PERMIT NO <br /> +EH 13-241REV.1/85) <br /> EH 14-28 A ` <br />