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• APPLICATION{FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ,.A•'a <br /> �D <br /> i601 E. HAMILTON AVE., STOCKTON, CA ' <br /> �} Telephone (209)466-6781 , <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to the San Joaquin Local Hearth District for a permit to construct and/or natal€the work herein described Thin application!s <br /> > made in compliance with San Joaquin my Ordi ee No.549 for sewage or No.IW2 for well/purr:_­and the Rules and Regulations of the San Joaquin .,�u <br /> Local Health District. . 50� } ;i ��} tb�; '.0 8� ��3 � ' i <br /> t , . . qqr <br /> Job Address. &503� .� City `' � LotSize 3" a' PM <br /> 4 <br /> Nemo` rens <br /> Contractor's Name -- ---- License No. Phone 5 <br /> y ,TYPE OF WELLlPUMi: _: EW'vVELL� WELL REPLACEMENT i- DESTRUCTION ❑ <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑' <br /> r `+ DISTANCE TO NEAREST: SEPTIC TANK- Ei SEWER LiNES n0I SP_,'_ DISPOSAL FI.D. PROP. LiNE <br /> FOUNDATION AGRICULTURE WELL C.'THER WELL PITS/SUMPS. _ . <br /> a <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS , 4 ;. <br /> �^f,_,�IndusMal •-.� ❑Open-Bottom ❑ Manteca Dia.of Well Excavation Via.'of Well Casing <br /> ❑Domestic/Private 'gGrevel.Pock ❑Tracy Type of Casing Specificatlorls ' NTF <br /> ❑Pub1u A ❑Other ❑ Deita Depth of Grout Seal _�`—�� Type.of G <br /> 5 ❑,Irtipa�m �: _�4pprox..Dopth ❑ Ee5tern Surface Seal Installed by # <br /> z Rapair.Work.Dona ❑ Type of Pump H.P. State Work Done' _ r ' <br /> f ' ' .,Wali pegtruction'a,,:.:❑ Well Diameter Seating Materia!(top 50'i <br /> 3 ,b 1 <br /> Depth Filler Material(Below 50'1 t `t <br /> 4'"•r' TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION© (No septic system permitted if public sew3r n': <br /> available within 200 feet.) ' <br /> 7 Installation w311 seas Res€dance_T Commercial Other <br /> Number.of living units: - Number of,bedrooms ^� <br /> r Clltiracter of soli to a depth of 3 feet` Water table depth <br /> SEPTIC TANK •'. ❑' Type/Mfg Capacity— No. Compartments, <br /> PKG.TREATMENT PLT.❑ ` ' Method of Dlaposal wt <br /> distance to nearest: Well Foundation Property Line <br /> E � .. <br /> t° n LEACHING LINE ,,❑ Na-.&Length of lines Total lengthlsize <br /> ¢�cl n <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ' Number <br /> 7 SEEPAGE PITS ❑ 'Depth Size <br /> SUMPS P.EI Distance to nearest: Well_ Foundation Property Line •��. yMg w€ 'a- <br /> e 'DISPOSAL'PONDS" ❑ - <br /> " 'I hereby certify that.)have prepared this applkation and that the work will be done in accordance with San Joaquin county ordinances,state laws,end §" <br /> rules and'regulatioro of the Sen Jcaquln Local Health District. , <br /> L,,,A'K'�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 •�, ' F <br /> v employ any person in such manner ss to beaime subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> Certifiaa-tile folowillig- certify that in the performance of the work far which this permit la Issued,I shall employ persona aubJeet to workman's compansa <br /> tion Iowa of Cellfomia' 4r <br /> ^Thai epplir� ust call'for all rsqui na. Com ate drawing on <br /> Signed <br /> Title: t Date r•}. <br /> t: €`5• '3 � .«* > y R DEPARTMENT US ONLY <br /> ASicatlon Aeeeptad by Data .r Area s <br /> „ <br /> h Pit Grout Inspection by: t Dates a w Final I by "S `� D� jt <br /> j � Additklrlal.Comments: � U 1 a_.{. N�. <br /> ('lEi(Stk 468-8781 . Lodi 38E1`3E41 ❑ Manteca 823 7104 T <br /> y Applicant-Return all copies to:En*mr metal Health Permit/Services 1801 E.Hazelton A%v., P.O. Box 2008,Stk.,iCA 9W1 '{ I e •t�4, ° �M <br /> FEE rs <br /> INFO AMOUNT DUE - AMOUNT REMrrrEO N ' RECENED 8Y DATE FERMIS NO. <br /> f :EH 13-M IREv.loran �, o o ��►1-7EK 14,111 <br /> t _'.".^..:..'.."'"�"'"'•i.,^-.^"rrnr�,tk,�17 x kA "5q - <br /> '� nrr• �`�ry.�u d11',�-":,x L3��i. r�.;��"5 4 � f �i' '. �F.,ryc�t:.._>'�� 'a` <br />