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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1602 E. HAZEL T ON AVE., STOCKTON, CA -� <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-!YEAR FROM DATE ISSUED <br /> w ' v (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a l� f <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage yr No. 1862 for well/pump and the Rules and Regulations of the Sart J } <br /> permit to construct and/or install the work herein described,This application is <br /> Local Health District. }fjf� <br /> Joaquin <br /> Job Address C` /clQ��' _ i y7 /���� S, �' � 1 <br /> ..-. ,�= <br /> /�, /� Lot Sizef PM <br /> Owner's Name Y �- f"�1/�fS AQQ Rex <br /> !� Address <br /> �C C07,!F Phone Z��`l�67�isf ( M <br /> Contractor Address ,�/J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ License No. S`O0'rT . <br /> WELL REPLACEMENT ❑ —�—Phone <br /> Mp INSTALLATION ❑ DESTRUCTION ❑ - - <br /> DISTANCE TO NEAREST: SEPTI SYSTEM REPAIR ❑ OTHER ❑ <br /> �— SEWER LINES DISPOSAL FLD. f o <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE TYPE OF WELL PROBLEM AR OTHER WELL__ PITS/SUMPS <br /> ❑ Industrial60- <br /> NSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca <br /> ❑ Domestic/Private Dia• of ovation <br /> ❑ Gravel Pack ❑ Tracy4� Dia. of Well Casing <br /> EJ Public Type of Casing x <br /> ❑ Other ❑ Delta Depth of Grout Seal Specifications <br /> El Irrigation _—Approx. Depth Type of Grout "; <br /> Repair Work Done El Type of Pump -- Eastern Surface Seal Installed by <br /> a <br /> Well Destruction LDH'P' State Work Donees T <br /> Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO <br /> DESTRUCTION ❑.(N°septic system permitted if public sewer is <br /> Installation will serve: Residence available within 200 feet.) <br /> Commercial 'Other L!�a������ <br /> Number of living units: Number of bedro_oms s`K' <br /> Character Of soil to a depth of 3 feet: A� I A <br /> SEPTIC TANK TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. 0 Capacity No. Compartments' ! <br /> Distance to nearest: Wo Method of Disposal <br /> Foundation" Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED _ Total length/size <br /> Distance to nearest: Weil �t: - Foundation ^�O <br /> l -�Z� Property Line I <br /> SEEPAGE PITS <br /> ❑ Depth ? Size --- <br /> SUMPSNumber <br /> ❑ Distance to nearest: Wel! Foundation <br /> DISPOSAL PONDS ❑ y .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 laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this per 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 far which this <br /> tion laws of California." permit is issued,i shall employ persons subject to workmari's cbmpensa <br /> The applicant must ca r all req dins ons. Complete drawing on reverse side. <br /> Signed � � �7 r <br /> Title: Date: &7> <br /> FOR DEPARTMENT USE ONLY f t <br /> Application Accepted by L� 4 p f 1 <br /> Date l Z} Area O <br /> Final IL J <br /> Pit or Grout Inspection b Date <br /> Inspection by Date - <br /> Additional Comments: <br /> 0 Stk_4¢6-6761 ❑ 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 95201 Y 1 <br /> FEE gMOUNT DUE CK t <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE ;Mn­�JNO. <br /> EH 13.24 IREV.1i a s1 <br /> EH 14-28 � _t_ 10 <br />