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V,6 77 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ll the work <br /> is <br /> ration is <br /> Application <br /> compliance withdSano the San Joaquin Joaquin County Ordinance No. 549 for sewage or ealth District for a permit <br /> No. 1862 for well/dpump and the Rules and herein <br /> R Regulations of Ithe SaniJoaquin <br /> Local Health District. C <br /> Job Address <br /> 3•��S.J •+ City Size PM <br /> ess —� �F a siw iv� Phone <br /> Ow is Name co <br /> Q i <br /> Contractor `IL dress <br /> Licensee No.10,373 7 Ptlone IJV <br /> TYPE OF WELL/PUMP: NEW ELL El , WELL REPLACEMENT ❑ DESTRUCTION Cl <br /> PUMP INSTALLATION11 SYSTEM REPAIR OTHER 71DISTANCE TO NEAREST: SEPTIC TANK "t SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ MDia. of Well Casing <br /> anteca Dia. of Well Excavation <br /> k<'omesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I <br /> I 1 Irrigation _.-Approx.`Depth 1 1 E stern Su Seal Installed by <br /> Repair Work Done Type of Pump " H.P. State Work Done <br /> E Sealing Material. <br /> 50';1 ►/" <br /> Well Destruction ❑ Well Diameter 9 p <br /> Depth <br /> f -�- - Filler-Materia{-IBelow5Q'1� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I I<REI AIRlADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> J� y available within 200 feet-1 <br /> Installation will serve: Residencd_ Commercial r Other <br /> Number of living units: Number of bedrooms' <br /> Character of soil to a depth of/3 feet: I Water table depth <br /> l s <br /> SEPTIC TANK ❑ Type <br /> I Capacity No. Cofnpartments <br /> Method of Disposal <br /> I PKG. TREATMENT PLT. ❑ 1 (� <br /> / Distance"to nearest: Well Foundation Property Line 7 <br /> ' Y ;``� r Total length/size <br /> LEACHING LINE �' � CI No. & Length of.11nes � ' <br /> r 11 , <br /> FILTER BED �+❑ Distance to nar"esf Well Foundation Property Line <br /> SEEPAGE PITSI 1 Depth Size Number <br /> SUMPS fr, 0 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 regular' o t San Joaquin Local Health 0Mrict. <br /> Home owner licensed age is signature certifies a following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any erson in such nner as to ecome u jest to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies t following: "I c y tha n rf m ce'of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> I tion law of Cali rnia." <br /> t The ap lica t� all all r u, i o plete drawingon side. ~ <br /> date: <br /> Signe )X( Title: r <br /> fOR DEPART NT USE ONLY <br /> r� <br /> Date U �J Area <br /> Application Accepted by <br /> Date <br /> Pit <br /> Pit or�Grout Inspection by _ `-1 Dafe Final Inspection by ' <br /> `lam_ <br /> 4 Additional Comments: <br /> 12rStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> i <br /> + EH 13-24 Msv-i/K51 �""L fl `� <br /> EH 14.26 __ <br />