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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> Z 9601 E. HAZELTON AVE., STOCKTON, CA <br /> + Telephone (209) 468- 31/20 <br /> 1 PERMIT EXPIRES I 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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R"ulations of the San Joaquin' <br /> Local Health District. <br /> Job Address 56 PAC-IF lo- At'E E. (Pfktlr-f Q � Kf)$INOCity STkr�� Lot Size 00 r 0_kzs PM <br /> Owner's Name Q� 1� tAL' 1?D1 P' Address °Z 1 u' CA4IFORuI4 W1►tT er1k Phone <br /> 5PEt1TRCIM 1EXPLOR4Tl0hr, .] o�DY' <br /> Contractor_ Address gZ 5 �� M YRTI-� �rl�• License No. ��'�°��°� Phone 9`/$- /34/S_ <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` Ol <br /> DISTANCE TO NEAREST: SEPTIC,TANK__,,.___ SEINER LINES - -,DISPOSAL--f I.D.= - - _- PROP. LINE, - + <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pEEp Id15L.L f 2 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation S" Oia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing SCIS• y0 PICC. (4r.4� <br /> Tracy yp g T 7SpecifiCations <br /> FI Public N Other #3 sAwD l'1 Delta Depth of Grout Seal V£5~� p�k 30Type 7:,-Sp Grout <br /> I i Irrigation /_Approx. Depth I I Eastern Surface Seal Installed by KL.EIN FEf_pE1Z /SPEC <br /> VF-5 �" VE S- 140DEEP- 60H.P. State Work Done_ <br /> i DEEP m0N>_ Well Diameter Sealing Material (top 50'1 <br /> 14"UToRNY(+ Depth Filler Material (Below.50.1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION( I REPAIR/ADDITION I I DESTRUCTION I INo 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 n <br /> PKG. TREATMENT PLT.Ll Method of Disposal (V <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line _ <br /> SEEPAGE PITS I I Depth Size Number_ - - <br /> SUMPS L1 Distance to nearertt: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicatl6n 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 net <br /> employ any person in such manner as to become subject to workman's compensation laws of Califomis."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 leaned,I shall employ petrsons subject to workman's compensa. <br /> tion laws of California." 1 <br /> The applicant must c�&Ired:' 7ions, Complete drawing on reverse side. <br /> Bignell x Title: Reemr; �..�fsT /9 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted Data Area r <br /> Pit of Grout Inspection by Date Final Inspscti AfbI Date c�`)z`�g <br /> / <br /> Additional Comments: ' <br /> ❑ Stk 466.6781 0 Lodi 359-3W1 0 Manteca 823-7104 0 Tracy 835-6386 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 15D1 E. Hazelton Ave., P.O. Box 20D9, Stk., CA 91001 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO, <br /> �i� VVV <br /> s EH 1INFO <br /> -24IFEV.r/Mbl <br /> CH t44a 9 <br />