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qw'y <br /> APPLICATION FOR PERMIT <br /> SAN ;QADUIN LOCAL HEALTH DISTRICT <br /> :.' „ 1601 E. PAZELTON AVE., STOCKTON, CA 4 <br /> f ao Tsiephane (209) af$-67$1 <br /> K PERMIT EXPIRES I YEAR F90M DATE ISSUED'' <br /> (Cnmrilete in Triplicate) <br /> Appl' ation is hereby made to the San Joaquin Local Health District oormit to construct and/or install the work herein descnbed.,Thrs apPton 1s a <br /> made in compliance with San Joaquin County Ordinance No. fo" vage or No.1862 far well p p and the Rulerz end Regulations of theSanJoequln <br /> .p J � <br /> �'- Local Health District. C7 ttL � `- <br /> s / City <br /> Job Address J <br /> n Owner's Name � hone <br /> ddress <br /> ' ������ _License No. _Phone j <br /> contractor <br /> —Address _ <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT D. DESTRUCTION C] <br /> d <br /> OTHER ❑ <br /> • PUMP INSTALLATION E7 SYSTEM REPAIR ❑ s <br /> "DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> •'. 'fir, <br /> FOUNDATION AGRICULTURE WELL -- OTHER WELL _ PITS/SUMPS <br /> P <br /> IN USE TYPE OF WELL PR08CENiAREA CONSTRUCTION SPECIFICATIONS 0 , <br /> ^� ❑Industrial ❑Open bottom ❑Manteca Dia, of V1o11 Excavation Dio.of Well Casing <br /> Specifications: r `r / LT1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑1 Tracy Type of Casing { <br /> ❑Public ❑Cher i� belts Depth of Grout Seal Type of Gtaut <br /> ❑Irrigation --Approx. Depth E3 Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump — H.P, State Work Done <br /> Woll Destruction ❑ Well Diameter Sealing Material[top 50'I _. y <br /> Filler Material(Below 50'} <br /> 7r'.. Depth <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION RE?AIRlADDITIUN❑ DESTRUCTIONCI (Noave septic system permitted if public sewer is ` <br /> available within 2t)D feet.) f111 <br /> Installation will serve: Residence.,_,— Commercial! other <br /> Number of living units:� Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: t <br /> Ca ani No. Compartment <br /> SEPTIC TANK ( TYhe/Mf9 P <br /> PKG.TREATMENT PLT.G / / Method of�Dispir r yP <br /> Distance to nearest: Well�(�_ Foundation <br /> Property Line- <br /> LEACHING LINE L9�o.&Length of lines�. •otal length/size' <br /> -' �. <br /> FILTER BED D Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS E7�Depth _size---- Number <br /> 7. <br /> ;t �3 MPS ❑ Distance to nearest: Well f�d-- Foundation,� Property Line <br /> tl <br /> DISPOSAL PONDS ❑ ` '1'U <br /> 1-heroby 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 /> y Home owner or licensed agent's signature certifies the following:"I certify that in the per`.ormance of the work for which this permit is issued,!.shall not' <br /> n g{npley any person in such manner as to become subject to workman's compensation laws of California."Contractor s hiring or sutiwntracting signature <br /> eerttfies the fo[towing:"I ce ' that in the�cr'ormance of the work for which this permit is issued,I shell employ persona subject to workman's oompensa .a <br /> Non taws of California." r f�+ { <br /> r.t The applicent mus red ections. Complete drawing on raver e. f y. <br /> �. }L <br /> .. T�nll�N Title: Data: 11 , <br /> Signed ' <br /> FOR DEFARTMENT USE ONLY <br /> � � - J 'AreaApplication Accepted by " Date4 <br /> 'i Pit or Grout Inspecilon by Date final inspection by Date <br /> ,kdd;tional Comments: 's 1 �� r �r <br /> v irk �8n 8781 C] Lodi 3621 ;.7 Myr teca 823.7104 ❑Tracy 835-6385 !,I <br /> t f Applicant•Return all eoP>�to;Environmental Health Permit/Services 16,01 E. Hazelton Ava., P^-•+BGx_ 2009,Stk.,CA 95201 <br /> rte» <br /> .R <br /> INFOFEE AMOUNT DUE AMOUNT REMlTTEt] GASH RECEIVED BY DATE PERMIT`N0. <br /> ,. 4•,.- �' EHf124111EV.f/e67 S. 0 10 c� <br /> EH <br /> �t i <br /> � •f � y <br />