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_+ APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT . <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 416-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1882 for well/ um and the Rules and Regulations of the San Jis <br /> Local Health District. p p f the <br /> application n <br /> � Joaquin <br /> Job Address 7-5- <br /> vel <br /> i CityLot Size PM <br /> �� Pri <br /> Owner's Name � )d f2C�� Address 2 Z 57 C�I ' vr- -- <br /> Phon 767 -2 <br /> Contractor ddress z Zf).IUB / � q 5 3 3 C9 <br /> TYPE OF WELL/PUMP: cense No.�G$33 z(Q Phone Z-2NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKOTHER E3SEWER LINES DISPOSAL FLD. <br /> ,see 2 til GJ. FOUNDATION AGRICULTURE WELL PROP. LINE <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ti Z If <br /> ' <br /> Dia. Of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private �f Gravel Pack �Tracy <br /> El Public Type of Casing P✓Q Specifications <br /> ❑ Other Delta Depth of Grout Seal { 5r-� <br /> El Irrigation �S Approx� ❑ D <br /> Depth ❑ Eastern Type of Grout � <br /> Repair Work Done L3 Type Surface Seal installed by <br /> - <br /> Repair of Pump H.P. State Work Done <br /> � Well Destruction ❑ Well Diameter ff Sealing Material {top 5011 <br /> Movhjyl� WU1 Depth Z <br /> Filler Material (Below 501) <br /> OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic stem { <br /> € P y permitted if public sewer" <br /> Installation will se . esidence_ Commercial_ Other available within 200 feet.) <br /> Number of living units: mbar of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg} Water table depth <br /> PKG. TREATMENT PLT. ❑ <br /> Capa " No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Wellndation <br /> > Property Line <br /> LEACHING LINE ❑ No. & Length of <br /> FILTER BED I length/size <br /> ❑ Distanc nearest: Well Foundation <br /> I r Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS DiNumber <br /> ❑ stance to)nearest: Well Foundation <br /> DI AL PONDS ❑ Property Line <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 focus, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: 'T certify that in the performance of the work for which this permit is issued, 1 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 <br /> tion laws of California." Permit is issued,f shall employ persons subject to workman's compensa <br /> The applica us all r all re uir s <br /> q pections. Complete drawing on reverse side. <br /> Signed <br /> Title: <br /> Dat "'. sj 1 <br /> e <br /> f - R E ONLY w �Y L71- =. 1 <br /> s <br /> Application Accepted b <br /> Date <br /> Pit or Grout Inspe io y <br /> Date Final Inspection by <br /> Date n <br /> Additional Comments: <br /> 0 Stk 466-8791 ❑ L 1 368 1 ; Manteca 04 ❑ Tracy �_� <br /> Stk., CA <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Be t <br /> s _ <br /> . <br /> FEEjAMOUNjDUE <br /> INFO AMOUNT REMITTEDCA�R RECEIVED BY DATE PERMIT NO. <br /> ♦ EH 13-24{REV. /B 5) p /^ �-7� 1 <br /> EH 14.28 97g7._"i 6 6�0�//�!, <br />