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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . 4 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 'Joaor <br /> nstall the <br /> rk <br /> .This <br /> cation is <br /> Application is eieb with San Jae San <br /> County <br /> Ordinencie No.549 for sewage or ealth District for a permit <br /> 1862 for cwell/p.mlp and the Roes and herein <br /> Regulations of he Sans Joaquin <br /> madecompliance <br /> Local Health District. <br /> City Lot Size ISO PM <br /> Job Address <br /> Address Phone <br /> Owner's Nameblu�J�M_AYA <br /> 22 Q <br /> r r r O�] t License No. G Phone���+�S I, <br /> Contract Address <br /> TYPE OF WELL/PUMP: , ' NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ V. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> *" T <br /> #' r _ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK Y SEWER LINES <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE`OF WELL -,,PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing 7 <br /> ❑ Industrial ❑ Open`"Bottam. ❑ Manteca Dia. of Well Excavation <br /> r e';ISpecifications <br /> D <br /> Domestic/Private ❑ Gravel Pack 17Tracy Type of Casing <br /> Type of Grout <br /> [`I Public M Other ~�1, a F1 Delta Depth of Grout Seal _ <br /> 1 <br /> 1,1 Irrigation �Approx. DepthI ! Eastern Surface Seal Installed by + <br /> f <br /> H.P. State Work Done — <br /> Repair Work,Done_,, ❑ Type of Pump <br /> Sealing Material ltop 501 <br /> r Well Destruction ❑ Wel! Diameter <br /> Depth �TION <br /> terial (Bel w 50'1TYPEOF SEPTIC WORK: NEW INSTALL1 REPA�RDITION DESTRUCTION I I avlailabptic s in 200 feetit�ed if public sewer is <br /> Installation will serve: " ResicJence_ Commercial ther -, M <br /> ' Number of living units: � Number o edroom Water table depth <br /> f Character of.soil to a depth of 3 feet:-_ - - <br /> Capacity No. Compartments <br /> SEPTIC TANK'` ❑ Type/Mfg'= iA <br /> Method of Disposal <br /> PKG. TREATMENT PLT.-11- <br /> to---- ---� --- <br /> i Foundation Property Line <br /> I ; Distance nearest: Well <br /> -- �S, _ Total length!"siie <br /> LEAC ING LINE YNo & Length of lines + <br /> FILTER BED t - ❑ Distance to nearest: Well .5a Fau dation --- Property Line <br /> Size x"rt �, r Number. <br /> I SEEPAGE PITSf" - { Is Depth 9 t '_ <br /> SUMPS f L1, Distance to nearest: Well Foundation Property Line ^+ <br /> DISPOSAL PONDS ❑" i �- , <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 Sa)-Joaquin-Local"Health Di%trict. <br /> 1n the,-perlormance of the work for which this permit is issued, I shall not <br /> Home owner or Acensed agent's signature certifies the following: "I certify/that signature <br /> employ any person in such manner as to`become subject to workman's compensation laws of California." Contractions hiring <br /> sub subject to workman's sub-contracting ompensa- <br /> cartlliLes the following: "!certify that in the performance of the woc'for which this permit is issued,l shall,Omploy p I <br /> tion laws bf California." <br /> 1 T <br /> The applicant st call for req 'red-inspections.-Complete drawing on reverse <br /> Date: - <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> pate 42 ..r S`` Area <br /> Application Accepted In <br /> Date Final Inspection by -" Date <br /> Pit or Grout Inspection by <br /> y!�- <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> r _ <br /> FEE <br /> =LRiFRECEIVED BY DATE PERMIT NO.AMOUNT DUE AMOUNT REMITTEDINFO � � yEH 13-24 1REV.1i 1151 ' - -q <br /> - EH 11-28 -- <br />