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n <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> : Telephone (209) 466-6781 <br /> PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> (Compieta in Triplicate) <br /> Applicafion is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This appfintlon is <br /> made in compliance with San Joaquin County Ordinance No.So for sewage or No.lien for welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. l r� <br /> I Job Address � � r KD city cn 1 Lot Sim PIN <br /> Owner's Name rn Q P Address S Phone _. .. <br /> Contractor <br /> ( t�� ddress_�J�/b RY � License No. <br /> A �Phone �'T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ­ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> G7 Industrial ly Opsn Bottom ❑ Manteca Dia.of Well Excavation Dia. WeR mg <br /> ❑ Domestic/Private G�Gravel Pack Q Tracy Type of Casing__ SpecwMtions <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Typo of Grout <br /> ❑ Irrigation ___Apprcx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done a Type of Pump H.P.. State Work Done <br /> Well Destruction C Well Diameter Sealing Material(top 501 <br /> Depth Filler Material(Bel 1 <br /> # TYPE OF SEPTIC WORK: NEW INSTALLATION W REPAiRIADDITION V DESTRUCTION❑ lNo septic system permitted if public sower it <br /> availabto within 200 feet.) <br /> Installation will serve: Residence_!� Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth o13 feet:— ,L Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No.Compartments <br /> I PKG. TREATMENT PLT,C Method of Disposal <br /> Distnnce to nearest: Well Foundation_ Property Line <br /> n _ thlsize <br /> LEACHING LINE W No. 8 Length of lines Total lenp <br /> �, � �"' <br /> FiLTEtR BED EI Distance to nearest: Well—� Foundation s— Property Lintt. n <br /> i � <br /> SEEPAGE PITS ❑ Depth . —Sire Number <br /> SUMPS C- Distanceto neares': W "_ Foundation Property Line <br /> s DISPOSAL PONDS ❑ I <br /> ' d that the work will be done in accordance with San Joaquin county ordinances,stela laws,and <br /> I hereby certify that 1 have prepared this application an <br /> i <br /> rules and regulations of the San Joaquin Local Health District. <br /> rtify that in the performance of the work for which this permit is issued,I shop not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> employ any person in such manner as to become subject to workman's compensation laws of California.,,Contractor's hiring or sub-contracting signature <br /> certifies the following;"I certify that in the performance of the work for which this permit is issued,t shall employ pnrsons subject to workmen's comr <br /> pee- <br /> tion laws of California." <br /> The applicant must call for all requin,d inspections. Complete drawing on reverse side. <br /> % ,,�(,tc. Title: pate: <br /> Signed _ <br /> ?(_,._�s�Lty wr' <br /> FOR DEPARTMENT USE ONLY <br /> sag-SI 06 <br /> Q�i.Gt/i^ ate Arar <br /> t <br /> Application Accepted by <br /> 1 V 1/1 Date Final in <br /> by /✓ � Die <br /> Pit or Grout Inspection by _.'—'—Cy <br /> Additional Comments: <br /> ❑ Stk 466-UMI ❑ Lodi 359.3821 enlace 823-7604 CJ azollTrac83548385Ave., P. ` <br /> Applicant• Return ell copies to: Environmental Health Permit/Services [501 E. Hazelton .. P.O. Box 26109, Stk., CA 9520[ <br /> FEE AMOUNT REMITTED CK= RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE CASH <br /> • EM 1331 fREV.� � �.1�l 6 <br /> !�_ <br /> EM,..x <br />