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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> "CelephOrie {209) 466-6781 <br /> yPERMIT EXPIRES ''YEAR FROM DATE ISSUED It <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 Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �55 R&Y� 010 COURT City Sl MQUILm Size _ PM_ <br /> Owner's Name DAVED FIICKELS Address SADa Phone957­1 I 0 <br /> Contractor ==- G Address PO BOX18 License NO37_=a <br /> Phane"}� <br /> TYPE OF WELL/PUMP: NEW WELL [J* WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> y. PUMP INSTALLATION*Ci SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE O <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i i <br /> L �bomesticlPrivate� 4 � _ _ Dia. of Well Casing <br /> travel Pack ❑ Tracy Type of Casin <br /> 9 Specifications <br /> f`I Public f 1-1 Other, n Delta Depth of Grout Seal <br /> --I nc) Type of Grout Q _ <br /> I 1 <br /> 1 Irrigation `230__Approx. Depth i I Eastern Surface Seal Installed by nn,xrY•�n. ��, <br /> .r. J <br /> Repair Work Done -• ❑� Type of Pump TT-i� H.P. State Work Done_ <br /> Well Destruction ,❑ s Well Diameter. Sealing Material (top 50'1 <br /> �, 'Depth Filler Material (Below 50') <br /> (gyp TYPE OF SEPTIC WORK:t NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) �\ <br /> Itlnstallation will serve: .Residence— Commercial— Other �� I <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of.3 feet: Water table depth <br /> v SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl <br /> Method of Disposal <br /> (Distance to nearest: Well Foundation Property Line f <br /> f <br /> LEACHING LINE ❑ No. & Length of lines � Total Length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 6 <br /> SEEPAGE PITS PITS f I Depth Size _ Number <br /> SUMPS` . "'El Distance to nearest: Well Foundation Property Line �. <br /> DISPOSAL'PONDS -❑ I `_fir - <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 l <br /> 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 /> certifies 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."' <br /> The applicant rnu_st call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 90-1 N t R Date: __9°-10-39 <br /> FOR DEPARTMENT USE ONLY QCy <br /> Application Accepted by Data — v r <br /> GJ Area <br /> Pit or Grout Inspection by Date / <br /> Final Inspection by-: Data / <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 ❑ Tracy 835-6385 <br /> w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 +r <br /> FEE MOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> + EM 1124 1REV.tirt51 <br /> EH t4-26 ` <br /> `�� � .- �/ I C _�+ C�-^— ✓ <br /> V -D U ryJo � <br />