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i C <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ANO 'well. o►3��Q���� <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA F <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) � pVb <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 sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Qr Cit A <br /> y Lot Size PM <br /> Owner's"Name W -% ':�A', &2. Address--ki L. & '� r Phone <br /> Contractor Address O•,' License No. (l�.X�C- Phone <br /> TYPE OF WELL/PUM : NEW WELL ❑ WELL REPLACEMENT ❑ - .DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> F AGRICULTURE WELL OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T e o. - I <br /> YP specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation __ Approx. Depth ❑ Eastern Surface Seal Installed by 4 <br /> Repair Work Done ❑ Type of Pump H.P. I <br /> State Work Done <br /> Well Destruction ❑ Well DiameterSealing Material ft—o50') E <br /> Depth P Filler Material"f Below 501 : <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> ailable 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 of 3 feet: Water table depth <br /> SEPTIC TANK .0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLTI. FJ i <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE -5-. ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation. Property Line <br /> SEEPAGE PITS ❑" Depth Size Number <br /> w� <br /> SUMPS ❑, Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS­0 <br /> ❑ <br /> 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." 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections- Complete drawing on reverse sidei <br /> Signed X `7 � <br /> Title: Date: —3 <br /> FO TMENT USE ONLY <br /> Application Accepted by Date 3 -0­0— Area <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date p <br /> (` r <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIYNO. <br /> "+ EH 13-24{REV.r i e SlS * <br /> ' EH 1428 <br />