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KIM= <br /> Ar} ' <br /> V l <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEAITH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466.6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pernsit to construct andlor install the work herein descrik <br /> i made in compliance wli.h San Joaquin County Ordir,anco No.549 for sewage or No.1862 for wel(lpump and the Rales arna Regulalrc <br /> Local Health District. <br /> i <br /> Job Address _ 1y/ <br /> .�. F -e� � -` City e----" Lot Size — <br /> Owner's Name <br /> ,4 1r!-r Phonr <br /> 1 }, <br /> Contfactor Address-A-5 / -- Li{ense No. Pho <br /> WELLIPUMP: NEW WELLV WELL REPLACEMENT El DESTRUCTION LJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LIQ <br /> FOUNDATION __ AGRICULTURE WELL OTHER WFLL PITS/SUN <br /> y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial El Open Bottom ❑ Manteca Dia. of Well Eftcavatian — Dia.of Well <br /> =<f t Cl Romestic?Private <br /> Type of Casing_) y Specification <br /> I Gravel Pack ❑Tracy YP <br /> ^fir rr Type of Gro, <br /> ['1 Public <br /> C1 Oiher CI Delta Oepth of Grout Seak _ ,�Ik <br /> * f I Inigad2 on � Approx. Depth l i Eastern Surface Seal Installed by— <br /> Z. -� <br /> Repair Werk Done ❑ Type of Pump H.P. Stats Work Done <br /> Well Destruction L1 Well Diameter A Scaling Material{top 501 <br /> Depth D.' Filler Material(Below 50'1 <br /> lA'T F S-PiIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted <br /> available within 200 feet.) <br /> S Installation will se • Residence— Commercial— Other <br /> '. Number.of living units: umber of bedrooms <br /> Character of sari to a depth of 3 feet: er table depth <br /> SEPTIC TANK D Type/Mfg Capacity No.Compartments _ <br /> PKG.TREATMENT PLT.❑ Method of Disposal_ <br /> Distance to nearest: -''.Nelldat of n Property Line _ <br /> 52 ngthlsize <br /> x LEACHING LINE ❑ No.&Length of lines <br /> FILTER BED CI Jistance Iaamrst: Well Foundation Prop ins <br /> cNumber <br /> � SEEPAGE PITS Depth Size <br /> ' SUMPS L1 Distance to nearest: Well Foundation_— Property Line <br /> DISP09ALPONDS fJ <br /> hereby certify that I have prepared this app!ication and that the work will be done in accordance with San Joaquin county ardii <br /> rules and regulations of lha San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"1 certify that in the performance Lf the work for which this per <br /> employ any person in such manner as to becOfTte subject to workman's compensation laws of California."Contractors hiring or st <br /> certifies the fallowing:"1 certify that in the performance of the work for which this permit is issued,I shall employ persons subject tr <br /> 'r`w+ tion laws of California1 <br /> The applicant must all f allrequired i peMmpl a drawing on reverse side.L � l Ad f <br /> _ itle: Data: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Date Area <br /> - Dateh°�2_-�Fi al Inspection by frit./ <br /> Pit or Grout Inspection by - <br /> d Additional Comments: <br /> I] Stk 466.6791 C7 Lodi 369.3621 D Manteca 823-7104 ©Tracy 835.6385 <br /> Appficart-Return all copies to: Environmental Health Permit/Servlc6s 1601 E. Hazolton Ave., P.O.Box 2009,Stk., CA 95201 <br /> s <br /> h7 FEE gMOUNT DUE AMDNNT REMITTED RECEIVED BY DATE PEI <br /> INFO <br /> , SS� ��- <br /> ��,' ,EHtszlraEv.+r>.g, <br /> EH 1146 <br /> h <br /> _ 1t�N1 <br />