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0 APPLICATION FOR PERMIT LL <br /> , <br /> w SAN JOAQUIN LOCAL HEALTH DISTRICT No �7� -JV' <br /> J 7"✓ "fi t6 & I (_ I <br /> 1601 E. HAZELT ON AVE.,_,STOCKTON, CA �, t n <br /> + y, ' <br /> Telephone (209) 466-6781 r O�D,lwl c1'� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. r <br /> (Complete in,Triplicate) <br /> rmit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Health District for a pe .1 <br /> or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.50.9 for sewage t <br /> Local Health District. <br /> LG K `Da K IG'o PM <br /> Job Address City of Size <br /> 01 <br /> Owner's Name Address Ph �e`�" <br /> Z Phone <br /> Contractor Address 3 S License No. .�-�2 — <br /> TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTORE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing a� <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal s Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth. Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONal o sepeiw system <br /> tem rmi`ed if public sewer is <br /> eet <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 <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal <br /> 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 ❑ Depth Size Number <br /> I SUMPS ❑ 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 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 /> 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 must call for all required/inspections. Complete drawing on reverse side. <br /> �( 5igned X <br /> 1 Lr 1!n (y7 ) c Title: <br /> RTMENT USE ONLY <br /> Date <br /> (+�Q,�. "T�_ o v f Area D <br /> Application Accepted by A <br /> Pit or Grout Inspection by Date Final Inspection by Date 0 <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-5621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> k Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> l + EH 13-24[REV,rin51 ��--�� � A '� LYJ „� - <br /> 1 EH 14-28 - <br />