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APPLICATION,,FOR PERMIT <br /> ''USAN JOAQUIN,LOCAL-1-119ALTH DISTRICT <br /> 1601 E-=HAZEL TON AVE., STOCKTON, CA <br /> ' " <br /> Telephone (209) 466 67 8i' <br /> PERMIT EXPIAESTY"I5A8'.FROM <br /> r I'OA_fEr ISSUED <br /> ­'bm aFin.M; <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 /> Imadb.irl.cornplianGe With San,loaquin-Cpunty'Ordinance No-,549,for sei/Vage.,or.No.-1862 for well/pump,ancl_the Ruies,and,Regulations of the San Joaquin <br /> Local Health District. <br /> i IWIII7 velgi lo iT S; Q <br /> n o I c�t tf i 71"?L <br /> PM <br /> City Lot.Size <br /> Job Address Q <br /> Owner's Name Address Ph-one <br /> -7- nom. -Or....( <br /> Contractor's Ni3ma : <br /> a <br /> C' 1 ffr icense No. Phone <br /> f"C� — <br /> TYPE OF,WELL/PUMP P11 NEW WELL 13 WELL REPLACEMENT 0 DESTRUCTION C3 e-- <br /> PUMP INSTALLATION 0 SYSTEM REPAIR D OTHER 0 _J <br /> DISTANCE TO WEAREST:. SEPTIC TANK. SEWER_.LINES, - FLO.— PROP.-LINE <br /> }FOUNDATION i I AGRICULTURE WELL OTHER WELL PITS/SUMPS 14 <br /> INTENDED USE i TYPE,OF WELL. PROBLEM EkIkEA CONSTRUCTION SPECIFICATIONS_ <br /> ❑ Industrial m 0,!Open Bottom..:-, 0.Mantebai Dia.+of'Weli-.Excavation Dia.hof Well Casing. <br /> # I _* , r��_k i . . <br /> Domestic/Private [],Gravel Pack El Tracy Type Of. asin Specifications <br /> Delta Type of Grout' <br /> Ic El Del Depth of Grout SOW <br /> ❑ PUN',-, n Other <br /> 'Cl pIrrigail6nilt— ---ApproxPu Depth 0 Eastern J Surface Seal Installed by <br /> Reair Work bone <br /> mPJA <br /> D <br /> L Ty H.P -Sift4ork Done <br /> pe of <br /> � - _ <br /> Well Desiructio'n 0! SIIDi6iiieiir (top 50r) T> <br /> -- Depth Filler Material iBelow 501 <br /> k� <br /> TYPE OF SEPTIC WORK: i NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation Will serve: Res idence commercial Other <br /> Number of living units: Number of bedrooms f <br /> Z,__ <br /> Character of soil to a depth of 3 feet: <br /> —Water table depth <br /> C'pacitv-11K_01V <br /> SEPTIC TANK [X�Type/Mfg_ No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Ditacearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER BED Distance to nearest: Well Foundation 0 Property Line <br /> SEEPAGE PITS 0 Depth 19 X 4e, <br /> Number <br /> SUMPS-., f " <br /> 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-Heafth 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."Contractor9's hiring or sub-contracting signature <br /> certifies the followirig: ",certify thei in the performance of the work or which this permit is issued,I shall employ persons subject to workman's compensa- <br /> -tion.laws,'of Californiai."� <br /> The applicant 11 for all rafird inspections C mplete drawing on eye7 side. <br /> SignedX_ Title: Da <br /> F- 4 <br /> FOR DEPARTMENT USE ONLY <br /> Date&- <br /> Application Accepted by. a, Is 0 <br /> D <br /> Pit or Grout Iri'spectio y Date Final Inspection by Date 41 <br /> j Vz <br /> Additional Co miments. <br /> El 9tk-4W>-6781- 0 Lod 369-3621 9\Wnteca 82&7104 0 Tracy 482ki-ey85 <br /> Applicani-Return all copies to: Environmental; ices 1601 E. Hazelton Ave., P.O. Box 2009,.Stk., CA 95201 <br /> 4- r FEEAMOUNT DUE AMOUNT REMITTED CK4V RECEIVED BY DATE" PERMIT`NO. <br /> INFO CASH <br /> CH 1 <br /> 324(REV.101831 <br /> EH.1428 <br />