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i APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �!VA P Qe Po. It,- 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . (Complete in Triplicate),. k <br /> Application is hereby made to the San Joaquin Local Health District fore V` <br /> 1 made in compliance with San Joaquin County 011 the wor <br /> rdinance No:549 for sewage No. 1862 for weand/or <br /> d/m nand the Rules ad described.This application is <br /> Local Health District. W P r • Regulations of the San Joaquin <br /> r <br /> Job Address ��^�y-�- /�� <br /> n i city� ��tL`Lot Size <br /> . PM <br /> Owner's Name JJ>/4 �j Address _ r: p;N 'p _ <br /> 1 ma/c-- c� Phone <br /> Contractor ,.�f.[)dr /rp .e/ c�1 T r I" { - <br /> Address �.� C Cps ! A <br /> TYPE OF WELL/PUMP: NEW WELL ❑ L.icense No.b (/ Phone <br /> WELL REPLACEMENT ❑ tDE$TQUCTON ❑ <br /> (PUMP INSTALLATION ❑ SYSTEM REPAIR Er <br /> DISTANCE TO NEARE57 PSEPTIC TANK OTHER O ` <br /> a SECNER LILINES' DISPOSAL FLD. <br /> "FOUNDATION ` L PROP. LINE <br /> AGRICULiLURE WELL.+ � <br /> INTENDED USE OTHER )VELE PITS/SUMPS <br /> TYPE WELL pROBLEM!AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ;❑r0pen Bottom ❑ Manteca- <br /> Domestic/Private 1 �' D��d1-WelfExcavation Dia• of Well Casing <br /> 1" ❑'Gravel Pack ❑ Tracy _Type of Casing1 <br /> ❑ Public ❑ Other _ • . Specifications <br /> ❑ Delta 7;"'Depth of GrouTSeal 4 T_._.I ; <br /> ❑ Irrigation ---Approx. Depth p❑ Eastern `+' ) .--ar""� \ Type of Grout <br /> Repair Work Done I% T �, /L s� Su sce.Seal Installed by • I <br /> / - Type of Pump H^P., <br /> Well Destruction ❑ State Work Done <br /> Well Diameter r i �.. I"r <br /> Sealing Msterial,lt 0'80'1 <br /> Depth 1 r-.`4 I 0 i , <br /> Filler Materiel JReIow­501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ <br /> REPAIR/ADDITION ❑ IDESTRUCTION O IN septic system permitted if public sewer is <br /> . ` }� available within 200 Permitted <br /> Installation will serve: Residence— Commercial Other ..r" l <br /> Number of living units: _ Number of <br /> bedrooms; v. <br /> Character of soy to a depth of 3 feet:. <br /> SEPTIC TANK ❑ Type/Mfg '' Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity l ' No. Compartments <br /> s Distance to nearest: WellI f Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE _1 Noj B Length of lures l <br /> FILTER BED Distance to nearest Well Total length/sr}e <br /> Foundation " <br /> Properf`1y,Line <br /> SEEPAGE PITS <br /> ❑. De - <br /> pth Siza <br /> SUMPS ❑;. Distance to nearest:. WellNumber ? <br /> DISPOSAL PONDS IDFoundation P.roparty_Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance wdti'Sanal aq ry ordin <br /> rules and regulations of the San Joaquin Local Health District. um court ances, state laws, and <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of �a work for which this permit rs issued, I shall not <br /> empty any person in such manner as m become subject to workman's compensation laws of Cslitorna..'Contractor's hiring or sub-contracting signature <br /> certifies the following:California."4 certify that in the performance of the work for which this <br /> tion laws of ClaPermit is issued,I sha'lllemploy persons subject to workman's comper,I <br /> The apps n u t call for all requ' mspec' . Co to drawing on reverse side. ' <br /> Signed X - e.� <br /> Title:' f,0 c 1 <br /> - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by/ / /[moi - <br /> Pit or Grout Inspectiory bv/ Die Date Z / �� Area�_ <br /> t/VV Final Inspection by Date � <br /> Additional Comments: _ <br /> ❑ Stk 466-8781 .❑ Lodi 3�-3521. ❑ Manteca 823-7114 ❑ Tracy 835-SM <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 9'oi 2009, Stk., CA 95201 <br /> _. -. FEE AMOUNT 6UE•`max. ' - <br /> INFO �_ AMU NTREMITTED,_ SrCA$H "( 3RECEIVED BY )- DA <br /> . EN IX24 aEV.vxs1 - -_ - - t - <br />