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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �* <br /> 1601 E. HAZE 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 /> or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage <br /> Local Health District. <br /> t ! v� L�� City � � Lot Size PM <br /> Job Address j <br /> � ro da Address 3 3 S/aeJ P 2t_c PA Phone R'3 <br /> Owner AN7 <br /> s Name � <br /> 5 <br /> + Address License No. Z-SY G Phone 4� 7 <br /> Contractor L® E � j <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAN'-- - SEWER LINES - - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom E Manteca of Well Excavation <br /> Dia. of Well Casing <br /> Type asin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack <br /> El Tracy 9 <br /> fl Public f 1 Other l 1 Delta Depth of G�eal Type of Grout <br /> I 1 Irrigation _..Approx. Depth <br /> I I Eastern Surface Se _ - <br /> RepairWork Done ❑ Type of Pump H.P. Staf&,Work Done _ <br /> Well Destruction ❑ Well Diameter °Sealing Material Itop 501 <br /> Depth Filler Material ibelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION l availseptiable wsystemithin rmiitied'if public sewer is r <br /> Installation will serve: Residence Z Commercial_ Other l \"fl, <br /> I <br /> f 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 /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I 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 <br /> SEEPAGE PITS ( I Depth ""Size— _ - Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ 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 <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 /> i 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 /> fcertifies 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." Lu <br /> The applicant must call for all required inspect' s. Complete drawing on reverse side. <br /> Date: <br /> FOR <br /> p_�� <br /> I Signed X E F, Title: �-�it <br /> f <br /> DEPARTMENT USE ONLY / <br /> Application=Accepted by (`f}-Jo{�L��l�•�. — Date Area I <br /> Pit or Grout Inspection by D f Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk' 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 1335-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ff AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> EH 13-24(REV.1/8 5f � U� /— <br /> EH 1 <br /> 428 <br />