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" t <br /> _r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.-HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rk herein described.This application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wo <br /> made in compliance with San Jo aq in County Ordinance No.549 forsewage or No. 1862 for well/p�p and the Rules and Regulations of the San Joaquin <br /> Local Health Distr!c A-V <br /> �+ City Lot Size PM <br /> Job Address �� - <br /> Phone <br /> Address <br /> Owner's Name <br /> Acne <br /> Contractor's Name _ �" License No, - Ph � �" �� j <br /> TYPE OF WELL/PUMP: NEW WELL WELL REDESTRUCTIONOTHER 61 f aux/ <br /> r-s ,PUMP INSTALLATION El SYSTEM REPAIR fl <br /> DISPOSAL FLD. PROP. LINE — <br /> DISTANCE TO NEAREST?SEPTIC TANK SEWER LINES PITS/SUMPS <br /> !FOUNDATION _ AGRICULTURE WELL OTHER WELL <br /> PROBLEM AREA y <br /> CONSTRUCTION SPECIFICATI N01 <br /> INTENDED USE TYPE OF WELL f� <br />` Dia. of Well Excavation Dia. of Well Casing <br /> L ❑ Industrial [I Open Bottom ❑ Manteca Specifications <br /> Type of Casing <br /> t ❑ Do stic/Private ❑ Gravel Pack ❑ Delta Depth of Grout Sea! Type of Grout <br /> ublic ❑ Other <br /> -L—Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ Irrigation State Work Dane <br /> H.P. <br /> f <br /> Repair Work Done ❑ Type of Pump �. <br /> Sealing Material stop 501 ; <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50') <br /> Depth <br /> j TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ avlall bleo so 4withine200 feettted!f public sewer 4s <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms Water table dept`' <br /> I Character of soil to a depth of 3 feet: No. Compartments <br /> ❑ Type/Mfg Capacity— <br /> SEPTIC TANK Method of Disposal <br /> f PKG. TREATMENT PLT. © Foundation Property Line <br /> Distance to nearest: Well <br /> 1 ff. 1 <br /> Total length/size <br /> LEACHING LINE ❑': No. & Length of Vines # _ ,-• -Q-. <br /> ' ` ' Foundation 'Property Line <br /> FILTER BED `. ❑• Distance to nearest: Well t - <br /> Size Number <br /> ^SEEPAGE PITS C3 Depth - 'Property Lina ' <br /> SUMPS 13 Distance to nearest:- 'Well Foundation <br /> DISPOSAL PONDS ❑ <br /> I 1 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. a work for <br /> l not <br /> Home owner or license agent's sigansa orbecome subject following: <br /> to workman's rcompensatfy that in ion laws he oof performance <br /> California." Contractor's or sub-contracting lsignlature <br /> employ any person in sas <br /> certifies the following:"I c that the performance of the work for which this permit is issued,I shall employ persons to workman's compen <br /> tion laws of fifo iia." <br /> The applica call r I <br /> ins ns. piete drawing on v so <br /> e. gam. <br /> Olt <br /> Date: <br /> Title: b <br /> Signed ' F <br /> j FOR.DEPARTMENT USE ONLY <br /> ' "Date Areae <br /> Application Accepted by <br /> ate <br /> Pit or Grout Inspection by <br /> Date_ F Final inspection by r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return <br /> all copies to: Environmental Health Permit/Services 10D1 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95 01 <br /> CKRECEIVED 8Y DATE PERMIT'NO. <br /> FEE AMOUNT DUE i AMOUNT REMITTED CASE{ <br /> INFO <br /> +EH 1&24(REV.50!63! <br /> E1414-28 _ _ _ <br />