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APPLIC TION FOR PERMIT f <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> n Triplicate) <br /> Application is hereby made to the San Joaquin Local Health Di rict for permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin Coun Ordinan or No. 1862 for well/pump and t Rules and Regulations of the San Joaquin <br /> Locale Health District// ,-7,T $�IPP��, 1 . <br /> f t C Lot Size [��: PM <br /> Job Address �� <br /> Owner's Name y4 is &I P--CAL f 6_ t-_`Address �P j.� ��0 L k_L 4 V I Phone <br /> Contractor Fil• Address �- t f 7 License Phone ' j`�­-2 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 1111 it-e- SEWER LINES DISPOSAL FLD.A dOAe PROP. LINE:-WZ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPSaltiC'- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial `Open Bottom ❑ Manteca Dia. of Well Excavation jr Dia. of Well Casing t <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing fsG Specifications <br /> I <br /> I-] Public 1-1 Other Ll Delta Depth of Grout Se ! Type Grout <br /> I I Irrigation 'O.Approx. Depth I Eastern Surface Seal.Instal _ t � k Ce <br /> Repair Work Done ❑ Type of Pump 1_� H.P. State Work Done _ r~ <br /> Well Destruction ❑ Well Diameter Sealing Material,Itop 50'I r <br /> Depth Filler Material (Below 50'1 —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if ' <br /> public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> 4 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> s <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS i I Depth Size Number s <br /> SUM 1s D 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 regulations of the San Joaquin Local Health Di?;trict. <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 California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call <br /> for all required 'nspections._Complete drawing on-reverse side. <br /> Signed �7/1 1 Title: _{� �w Date: =��'% <br /> FOR RT USE ONLY <br /> Application Accepted byDate C Area/y <br /> Pit or ro Inspection by Data ' ::I Final Inspection btJ �a„o/ Date / U <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> )NFO 41MOUNT DUE AMOUNT REMITTED CK CASH /JyRRECEIVED BY DATE PERMIT''`�NO.7 <br /> +.EH 13-24IREV.I/A5) 11 J [� �G�'/3J <br /> EH 14-26 <br />