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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI�TON AVE., STOCKTON, CA <br /> .� Telephone (209) 466-6781 <br /> PERMIT EXPIRES )'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> rmit to construct ardlor insult the work herein described.This apPlication is <br /> a No.1862 for well/pum9 and the Rules and Regulations of the San Joagwn <br /> App6caiatn is trail made w the San Joaquin Local Health 549for for a is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage rill 4dA(-' <br /> Local Health District. X17 PM �•' I <br /> City 1J.d�.� Lot S -g <br /> ia4 -s-�`- <br /> Job Address <br /> Phone <br /> r 2 r ) Address <br /> Owner's Name - _7 <br /> ho <br /> 1 .6 <br /> licensee <br /> Address P "v <br /> Contrattor� WELL REPLACEMENT ❑ DESTRUCTION O <br /> TYPE OF NEW WELL ❑ OTHER ❑ <br /> t SYSTEM REPAIR ❑ PROP. LINE _-- <br /> I PUMP INSTALLATION ❑ -- DIS FID. <br /> SEWER LINES _. PITS/SUMPS -- <br /> DISTANCE TO NEAREST' SEPTIC LANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION - <br /> -- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS .Dia. of Well Casiltg <br /> r INTENDED USE - - <br /> . . ❑ Open Bottom ❑ Manteca pia. of Wee Excavation-_ Spapifications <br /> i ❑ Industrial ❑Tracy Type of Caring- <br /> L] --. <br /> !�orrtestic/Private Car®vei Pack <br /> Depth of Grout Seal Type of Grout_- <br /> ❑ Dau <br /> G i I•' Public I� Oar Sed installed by <br /> 1 I I Inigalion --Approx. Depth 1 1 Eastern Surface Sofa work Dow <br /> H.P. <br /> Repair Work Done U Type of Pump Sealing Material (top 501 — <br /> ,=Well Destruction ❑ Well Diameter <br /> rt Depth-_ Piller Material IBelow 50'1 (� <br /> F available within 200 feet.l <br /> 'TYPE OF SEPTIC,WOflK: NEW IN STACL-- REPA ( I OESTRUCTiON I I lNo septic system permitted it pubkc sewer is <br /> Other . <br /> installation-Mserve: Residence�L Commercial— 4� <br /> 1 <br /> Number of living VMS: Number of ballrooms �Water table depth <br /> Character of soil to a depthof 3 feet: Capacity r r� No. Compartments, ' <br /> SEPTIC TANK � Type/Mfg Method of Disposal — <br /> PKG- TREATMENT PLT.❑ ; a Foundation Properly Line <br /> — <br /> Disunoe to rieatest: well <br /> '♦ ` - Total length/size x <br /> `s t No. & Length of lines at V� t"ti- - <br /> I LEACHING LINE s 12—_ property Line+ <br /> FILTER BED ❑ Distance to nearest: oil Found *✓ <br /> t _-- - Number._ <br /> SEEPAGE PITS I ! Depth y Sia� 7 O r Property LirN <br /> •rr„_...-,SUMPS'_ �,/' <br /> Distance"to ntiarest: .Walt 7/00 Foundation <br /> DISPOSAL PONDS G <br /> r I hereby certify that 1 have prepared the apDitcao°n and that the work will be done in accordance with San Joaquin coumy ordinances. <br /> state laws, and <br /> ` rules and regulations of the San Joaquin Local Health District. i certify that in the performance of the work for yyttx:h utas perrral s issued, I shall not , <br /> Home owner or licensed agent's signature centras the following: ' - <br /> empby any parson M such manner as to become St �of to <br /> he work for tMinch�'this tion permitt s ofOssuodrfI shah employ petrsons stblect w worktman's compense- <br /> c,ridies the following: •'i certify that in the Pett s- <br /> tion laws of California." - - - <br /> The applicant s cae for all required innpre hot%. Complete drawing o6 n iae side. <br /> Title: Date: <br /> Signed X_ _ <br /> r FOR DEPARTMENT USE ONLY 7 Z <br /> - Date Area <br /> pPacatan Accepted by <br /> •` <br /> SS Dater IRepectton <br /> w GW <br /> Tnspaction by .. .i.. <br /> Additional Comments: <br /> O Stk 466-6781 ❑ Lodi 369-3621 ❑ Menace S23 iCOI;. .- I ❑Traey l P O. Boa:7004, Stil CA 96201, <br /> Applicant - Vial all copies to: Environmental Health Permit/Services 1601 .HazepaD A <br /> t _ JVD <br /> ' K pECER1ED eV DATE FERMR'NO. <br /> FEE AMOUNT DVE AMOUNT REMITTED - <br /> tNFO <br /> ..EM UEq U�zs ttiEv.v x si �- 1 Y R� <br /> ( Et taaf <br />