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ti f APPLICATION FOR PERMIT <br /> . = SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HA2ELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6761 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s+• J*� (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/Or install the wok herein described.This application is <br /> 'made i±compiiancewith San Joaquin County Ordinance No.549 for sewage or No.1862 for well/pump and the Rules and of the San Joaquin <br /> I Local Health District. ax <br /> - <br /> il <br /> Jori A Y p�f TTC/GUa/ .w i./19LlC.e, Cllr/ O _ /!^�G2Lt:�., Lot Size PAA <br /> dress <br /> y <br /> Owners Name aaY'l°`6/ uJ /—UI^YY116 Address 9 l(l• YYYtic1Q1^GC �L1 STC�C rte 790 <br /> , <br /> ♦Cantracto r� • Address 'A - License No. Phone s� p <br /> TYPE OF WELL/PUMP: ( NEW WELL ., WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ( PUMP INST',ALLATION El SYSTEM REPAIR 11 OTHER ❑ <br /> E DISTANCE TO NEAREST: SEPTIC�hppiAlK 60ni _ SEWER UNES., - V DISPOSAL FLO.�I.PROP. UNE ` C, <br /> 1 FOUNDA'T70N AGRICULTURE WELL OTHER WELL PIT$/SUMPS-_ <br /> 7-4 <br /> INTENDED USE TYPE OF WELL 1 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> ❑ Domestic!Private XGravel Pack ❑ Tracy Type of Casing PVG Specifications <br /> ❑ Public ❑ Othertt ❑ Delta Depth of Grout Seal - Type of Grout <br /> Irrigation _Approxi Depthk ❑ Eastern Surface Seal Installed by <br /> I Repair Work Done C3 Type of Pump ( H.P. State Work Done <br /> ` Well Destruction ❑ Well Diameter ( Sealing Material(top 561 <br /> ' Depth i { Filler Material(Below 50') <br /> ,• TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted it public sewer is <br /> available within 200 tact.) <br /> Installation;vi llfse": Residence-1 Comrtretcial Other <br /> Number of living units:_ Number of bedrooms <br /> Character of soil to a depth of 3 feet t Watar table depth <br /> SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ - Method of Disposal <br /> Distance(t0 neareit: Well Foundation Property Line <br /> E <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distancetonearest: Well Foundation Property Line <br /> i 1 <br /> SEEPAGE PITS ❑ Depth �I F S1zB Number I <br /> SUMPS ❑ Distancerto nearest: Well FoundationProperty Una n <br /> DISPOSAL PONDS ❑ <br /> �i I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordinances,state laws, and <br /> \ rules and regulations of the San Joaquin Local Health District. <br /> ( 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-Contracting signature <br /> certifies the following: 'I cattily that in the performance of the work for which this permit is issued,I shall employ persons subject to workmans co <br /> i tan laws of California." <br /> 3 The sppll nt ust call for all rept i d inspections. Complete drawing arse J <br /> gtned <br /> Til <br /> Data: <br /> "h FOR DEPARTMENT ONLY t f� <br /> Data b—S 1 Area <br /> 'Appiicetwh Accepted byon <br /> k-or,G'rqut Irrepection I Date Final Inspection by Data <br /> q <br /> it i . r� <br /> 1 Addhronai Comments: <br /> • ❑ Stk 46"781 ❑ Lodi 369-3521 ❑ Manteca SM-7104 ❑Tracy 83 <br /> Applicant nvi <br /> Rewm all copies to: Eidnmemei Health Permit/Serviose 1601 E. Hazeiton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ti' a i <br /> CK d <br /> 4 FEE AMOUNT[)I AMOUNT REMITTED CASH RECFJVED BY DATE PERMIT'N0. <br /> NF0 <br /> .et lou MEv.,iss1 <br /> N W25 <br />