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-W LO e,kl— APPLICATION.FOR PERMIT <br /> SAN JOAQUIN' LOCAL HEALTH DISTRICT <br /> 3601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 , .,, 3 _` , ,. y� .q <br /> PERMIT EXPIRE Sy9 YEAR,FROM DATE.ISSUED <br /> (Complete in Triplicate) �� ' <br /> madecation is <br /> in co is hereby ith Sanvthe Joaquin County ordinance No.Districtan Joaquin Local Health 549 for sewage or permit <br /> No. 1862 forct a well pump and the Rules and-Regulations of the San or install the w0herei?A&9cribed.'This l Joaquin <br /> made in compliant <br /> jf� -,. t E. . '. ., Y <br /> Local Health District. .� + <br /> S 6 Wil! Loo.t <br /> � � 1 � v{ t _ _. fv <br /> .City _ S¢e <br /> 9-6 - .Q � <br /> Jab Address - - e �` <br /> Address _ ;J TM I �. Phone <br /> Owner's Name (f <br /> Kb License No. �2�—�� � _ Phone�L� <br /> Contractor's Name DESTRUCTION C1x <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ j r <br /> PUMP INSTALLATION SYSTEM REPAIR,C--/ AI I OTHER ❑ f <br /> SEWER LINES &SPOSAL.PLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTRER;WELL PITS/SUMPS �l <br /> FOUNDATION AGRICULTURE WELL _ ti <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> Ria. of Well Casing <br /> Industrial �❑ Open Bottom ❑ Manteca Dia. of Well Excavation SpeciFications <br /> k rx,Gravel Pack ❑ Tracy Type of Casing - <br /> ❑ Domestic/ S Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Public t . r <br /> ❑ Irrigation S OO�approx. Depth O`'Easterri `Surface Seal In <br /> staAed by : <br /> �1 H P _ State Work-Done --' t1 <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing MateriI (top 50'., <br /> ` r r <br /> Depth F,ilfer'Material;(Below;50'} V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION�REPAIR/ADDITION LJS DESTRUCTION ❑ alvailabpeiwithin820d feettted if public sewer is <br /> Installation will serve: Residences !,Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> u 1� i,� Water table depth \ <br /> Character of soil rota depth of'3 feet: A No. Compartments <br /> SEPTIC TANK # ElType/Mfg ; opacity <br /> i- Method of Disposal <br /> PKG. TREATMENT PLT:r. •' - "` t <br /> Property Line <br /> Distance to nearest: Well Foundation <br /> {I Total length/size ° <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> re FILTER BED' ❑ Distance to nearest: Well ' Foundation- - , <br /> ♦f 1 <br /> Size Nurilb'er <br /> SEEPAGE PITS ❑ Depth A ` P operty Line <br /> SUMPS ❑, 'Distance to nearest: " Well Foundation <br /> DISPOSAL PONDS ❑ - <br /> hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. rk for which this permit is issued,,I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the wo <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 /> cert"rfies the following:"I certify that in the performance of the work for whidh.tlhis permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California."- <br /> The applicant 11 for all require spectio . Complete drawing onifeverse side. ; <br /> µ Title: :_ i' S Date: <br /> Signed <br /> ` D3­`:s OR OEPMYM PT USE ONLY <br /> f Date--kK7- Area <br /> l Application Accepted by j <br /> r FDate a—cam <br /> Pit spa <br /> ction-b Final-Inspection.b � r <br /> a' Grout I Y <br /> Additional Comments: <br /> r 7 ' <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 8x3-7104 �Tra Y $35 63B�r . <br /> Applicant- Return all copies to: Environmental Health <br /> Permit/Services 1601 E. Hazeiton Ave.`,tP:O: Box 2009, Stk., CA 95201 r <br /> ,. <br /> FEE CK RECEIVED BY _ /�`DATE''' PERMIT"NO.' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> - q/I <br /> � + EH 13-24(REV.161831 1 l� d� +,'fly'' ��ytp �,QA .--..•i <br /> EH 14-26 „r - <br />