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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br />!=_ Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Apl3 <br /> .This <br /> cation is <br /> madeinIon is compli�ance with San Joaquin Corny OrdinJoliquin aHealth nce No.District49 for sewage or permit <br /> No. 1862 forcwell and/or <br /> pump install <br /> nd the Rules and Regulations of he San Joaquin <br /> Local Health District, <br /> Job AddressZx4c y AV 1 City r)-4c Lot Size /0,( X X60 PM <br /> I <br /> Owner's Name �/9y �� �Q Address ;X11ft �GG Phone <br /> + <br /> Contractor's Name p sOIC License No. � �— � — Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT-.D DESTRUCTION ❑ <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIOfN AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial C1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ElGravel Pack ❑ Tracy Type of Casio Specifications <br /> El Public Ll Other ' � L1 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �Approx. Depth ❑ EasterSu�r�a ce Seal Installed by`� ~� $ <br /> Repair Work Done 11Type of Pump H.P. ='State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material (Below 501 <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION;17—REPAIR/ADDITION ❑ DESTRUCTION Elalvail ble�wthine200 feet.) <br /> permitted <br /> if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> r Number of living units: 1 Number of bedrooms N <br /> Character of soil to a depth of 3 feet C OA � '""' Water table depth 8 <br /> SEPTIC TANK IN Type/Mfg A" C V,-7- � _Capacity_je;� � _ No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ , <br /> Distance to nearest: Well Foundation�roperty-L-ine� y0 i <br /> I � ( <br /> s�k — $t7 ' /N '= Total length/size <br /> LEACHING LINE J No. & length of linesy 1�.t.t 30, <br /> FILTER BED EJ Distance to nearest: Well� Foundation f Property Line <br /> ( SEEPAGE PITS ❑ Depth <br /> I Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line , <br /> t <br /> r <br /> DISPOSAL PONDS ❑ � l e <br /> 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. i• <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#ollowing i,'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 6f`Califor6ia:" ,. <br /> The applicant mu II for all required inspections. Complete drawing on`reverse side. a <br /> f t Title: L Date: <br /> Signed <br /> k ; F R DEPARTMENT USE ONLY <br /> ,{ b-,z�=SSV Area O 7 <br /> Application Accepted by Date <br /> i ��7e5 <br /> r <br /> Pit or Grout Inspection by Date Final I spection by Dat <br /> Additional Comments: <br /> ❑ Stk 456-6781 EDod'L369-3621 ❑ Manteca 823-7104 ; ❑ Tracy 835 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 / �� <br /> III IFEENFO ho'MOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324 IREv.t01e ) ^- <br /> s. EH 14.26 <br /> i <br />