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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> made in compliance with San Joaquin County Ordinance No.549 foJ Swage r o. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. /y70o cU I <br /> Job Address Ci Lot Size /6CLSPM„ <br /> 440 Address <br /> Owner's Name <br /> Phone LS�-5� <br /> Contractor I <br /> ' Address X License No. 4 Phone 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL'•REPLACEMENT ,t DESTRUCTION Ll <br /> PUMP INSTALLATION ❑ .SYST.EM REPAIR--Cl, 't. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL Y-PROBLEM AREA ICONST.RUCTION SPE <br /> GIFICATIONS <br /> El Industrial El Open Bottom ❑+Manteca �' Oia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy IType ofiCasing Specifications <br /> 3j Type of Grout <br /> ❑ Public ❑ Other LlDelta /Depth of Grout Beal <br /> ❑ Irrigation —Approx. Depth ❑ Eastern tSurfacelSeal Installe'd,byl 4 w <br /> 1 Repair Work Done ElType of Pump H.P. ¢ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler MatOal '(Belgw 501 <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public}sewer is <br /> ✓/ _� available within 200 feet.] a <br /> Installation will serve: Residence— Commercial— Other kl <br /> I Number of living units: Number of bedrooms <br /> 1 Character of soil to a depth of 3 feet: E � Water table depth p <br /> f SEPTIC TANK 7� ype/Mfg CiCapacity�� �a No. Compartments +� <br /> PKG. TREATMENT PLT. ❑ <br /> i �. Method of Disposal <br /> Distance to nearest WeIIFoundation.—Property Line <br /> LEACHING LINE �Jl --No. Length of lines � '�' �ToTal#length/size d <br /> _ <br /> V = FiLTEfi BED ❑ ' Distance to nearest: Well Foundation' ' Property Line <br /> SEEPAGE PITS ❑ Depth SizeVurr'tb r <br /> SUMPS ❑ Distance to nearest: Well Foundation _ Property Line [� <br /> DISPOSAL PONDS ❑ h <br /> t 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. [j %�_ 'i <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,Cali "fornia. Contractor's hiring or sub contracting signature <br /> r certifies the followin :"I certify that in the performanceofthe work-for.which-this.permit-is-issued;I shall employ persons•subject.to.warkmari.is compensa <br /> tion laws of Calif <br /> The applicant u c or 1 u ed i pectin . Complete drawingonr rse side <br /> Date; <br /> i Signed Title: - <br /> FbR DEPA'Fi7MENT USE'ONLY' <br /> r <br /> '. _ w` Dated Area:' - s ,s <br /> Application-A_ecepted bk ti - <br /> a <br /> Pit or Inspection by # ► Date I } Final Inspection by / Date <br /> Additional Cori ments: �D a <br /> "'°.❑ Stk 466-OMI L1 Lodi 369-3621 i ❑ Manteca 823-7104 0 Tracy� <br /> Applicant Return alt copies to: Env,�ronrnental ealth Pe i /Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 # <br /> 57. <br /> t <br /> ',FE AMOUNT DUE . AMOUNT RE ITTED CASH RECEICK# VED BY . 1DATE PEt! N�J.'. <br /> INFO I I v <br /> ( P 's ; g No <br /> + EH 13-24 IREV.t/a 51 <br /> I EH 1426 <br />