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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466.6761 , .- <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I ft ', C. _ application is <br /> Application is heiebY mala to the Sen Juin Local Health District for a permit <br /> No. 1882 for well/pump and the Rubs and herein <br /> ations of the San Joaquin <br /> made in compliance with San Joaquin Cb inty Ordinance No. for sewage <br /> Local Health 1.District. q - <br /> .. n 0a. <br /> 6 cStTtiY'JYIbf/ Lot Sizezt�-.4�<-*� PM <br /> :Job Address - <br /> ,a� Phone <br /> Owner's Name _ <br /> t✓e,6.c� /pf-Gt Address / yG <br /> - I � <br /> Contractor SQL c <br /> Address <br /> Liense No. Phone <br /> TYPE OF_ WELL/PUMP: - NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 11 <br /> ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER El' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SUMPS <br /> " . FOUNDATION AGRICULTURE WELL OTHER WELL <br /> CATIONS <br /> INTENDED'USE � '� TYPE OF WELL PROBLEM AREA <br /> CC TR PE t — Die. of Well Casing <br /> it 1 ❑ Open Bottom ❑ Manteca ell Excavation <br /> ❑ Industrial' ' Specifications <br /> i ❑ T t,.�ype of Casing <br /> ❑ Domestic/Private 1] Gravel Pack Depth of Grout Seal Type of Grout <br /> ❑ Public � (� Other ❑ pelta <br /> ❑ irrigation prox. Depth , ❑ Eastern Surface Seal Installed by <br /> ... <br /> H.P. State Work Done_ <br /> Repair Work Type of Pump _ <br /> truction O'.Well Diameter Sealing Material (top 50'1 <br /> RDepth . Filler Material (Below 50'1 <br /> { TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O' DESTRUCTION aNve11 be f d B public sewer is <br /> 11 .. �J • .j ti <br /> ommercial Other. . _ . . <br /> InsteBation'will serve: Residences • a �._.r 1 <br /> Number of Irving units: _ Nu of bedrooms .. Water table depth <br /> ECharacter of soil to a depth of 3 feet: 1 Ca city No. Compartments <br /> SEPTIC TANK ❑ TVP!/M10 Method of Disposal <br /> C3 <br /> TREATMENT PLT.C3t ° <br /> property Line <br /> D'istarito nearest: Well Foundation <br /> Total length/size <br /> ! r LEACHING LINE ❑ No. &length of linea ation ' Property Line <br /> 1 C.r FILTER BED ❑ Distance to nearest: ' -1 Well F�� <br /> - , • <br /> t Number <br /> srenCte <br /> SEEPAGE PITS C3 Depth 4 Size Property Line <br /> SUMPS ❑ Dito nearest- Well Foundation . <br /> DISPOSAL PONDS ❑ 111 f <br /> I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin county ordinances, state laws, enc <br /> rules and regulations of the San Joaquin Local Health District g- <br /> Home owner or licensed agent's signature certifies the folio "I Certify that in the performance the work for which this permit o issued. <br /> I shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California."IshllContractors hiring c ab-contracting sgnatuu <br /> certifies the following: "I certify that in 1 the performance of the work for which this permit is issued, I!hell employ persons subject to workman's compensa <br /> tion.laws of California." <br /> nt must call for all required ins ctbns. Complete drawing on reverse side.ilisesi <br /> Title: Date: � <br /> , <br /> Signed X `( <br /> �f FOR DEPARTMENT USE ONLY <br /> i Date ��Area <br /> Application Accepted by _ !! <br /> Pit or Grout inspection by DateFinal lnepactio by L' pane <br /> Additional Comments: ` 4 <br /> ❑ Stk 488-6781 Lodi 369-3821 ❑ Ms 8237104 . ❑ Tracy 836 OtfL/!LQ/" � <br /> Applicant- Return all copies to;Environmental Health Parrhln/Servlpes 1fD1 E. Hazelton Ave.. P.O:Box 2008. Stk., CA _ <br /> FEE AMOUNT DUE AMOUNT REMITTED g 1 <br /> RECENED eY DATE ._PEAMI7 fJO. r - <br /> lNrO <br /> 'a EH 13!!(REV ' <br />