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3 <br /> APPLICATION FOR PERMIT 0 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �Iti J <br /> 1601 E. HAZE,T ON AVE., STOCKTON, CA kJ 1 <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 Health District for a permit to construct and/or install the work herein described.This application Is <br /> made in compliance with San Joaquin County Ordinance No.549 for-towage or No.1862 for well/pump and the Rules 3rtd Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City _ Lot Size Z PM <br /> ti <br /> ' <br /> Owners Name C <br /> f• Address Phone <br /> j. Contractors Name icense No. Phone <br /> t } TYPE OfWELLIPUfMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION L1 <br /> PUMP INSTALLATION 0,: SYSTEM REPAFMTu OTHER 0 <br /> DISTANCE TO NEAREST.' SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> POUNDATIO14 T AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial 0 Open Bottom ❑Manteca Din.of Well Excavation Dia.of Well Casing <br /> k; ❑ Domestic/Private fJ Gravel Pack ❑Tracy Type of Casing. " Specifications <br /> k <br /> < v <br /> 0 Public I' � ❑ Other Ll Deka Depth of Grout Seal Type of Grout <br /> a ❑Irrigation L, Appm.-Daptht El.Eastern.._«—Surface Seal Installed by <br /> Repair Work Done Q Tye of Puhip I::y f , H.P. State Work Done <br /> Well Do. ruttion 0 WJII DiameterSealing Material(top 50') <br /> ti <br /> r <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION.❑ DESTRUCTION D (No septic system permitted if public sewer is <br /> '/ availabla within 200 feet.) <br /> Installation will serve; Residen _ Commercial IL Other 11 <br /> ,!] Number of living units: NumbeS of1pdroompf; <br /> Chann'tel of toil to a depttr of 3 feet: ZLdlAe Water table depth <br /> 3 SEPTIC TANK i TypelMfg ^ Capacity No.No.Compertmenta <br /> PKG.TREATMENT PLT.❑ , Method of D' I a } <br /> ?Dlstance to nearest: Wen Foundatior+1..Jf2:_ Property Line440 <br /> U �` <br /> KINE ❑~IIVo.8 Length of lines r Total length/sim <br /> iJ1 �LTER B ❑ Oletance to nearest: Well Foundation _ W Property Line <br /> SEEPAGE ;Depth _Size Number <br /> tx� SUMPS i ❑ ;Distance to neatest: Well Fbundationy Property Line <br /> �i <br /> D15POS L NDS 0 <br /> I hereby that I have prepared this application and that the work will be lona In accordance with San Joaquin county ordinances, state tswa,and <br /> rules avid of the San Joaquin Lace)Health District, <br /> FS hlpgEe4 licenced egettf's signature oartMles the following:"1 cartHy that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person M troch mariner as to become subject to workmen's compensation taws of Califomie."Contractor s hir[r►g of sub contracting aigneture <br /> ' aertiRaa the following: that In the performanoe of the work for which this taennit is Issued.l shall employ persona subject to workman's <br /> compensa-tion laws of California." # <br /> The aWlk ant for roqur pectiotts.Comp) rawinp on aide. <br /> i <br /> ` S vied --lntfa: Date <br /> i FOR DEPARTMENT USE ONLY <br /> F <br /> t��rOkadon AccepWI by Date 2 A <br /> Fluor Grout Inspection by r Date -Z Final Inspection byni Date <br /> Additional Comments: _ /� <br /> (3 Stk 4888781 0 Lod[ 3833821 ❑ Manteca 823-7104 ❑Tracy 83541M <br /> Applicant-Return all copies to: Environmerttet Haelth Permit/Services 1801 E. Hazelton Ave., P.O. Box 2G09, Stk., CA 85201 <br /> 2. <br /> FEE AMOUNT DUE AMOUNT REmr YEG nECENED BY DATE PFAMIT'NO. <br /> u; INFO CASH <br /> ?,r <br /> l ♦Vt.:, ,REV.Ceram 3 <br /> 1 EH 147a <br /> � - r <br />