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APPLICATION FOR PERMIT <br /> 4t r <br /> SAN JOAQUIN LOCAL'HiALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6* <br /> PERMIT EXPIRES 1 YEAR,FROM-DATE ISSUED <br /> (Complete in"Triplicate) <br /> Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin Local Hea p and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.50 for sewage or No. 1862 for well/pum <br /> Local Health District. <br /> 6ity PM <br /> Job Address, <br /> ME1- AE5T <br /> Owner's Name -Address Phone <br /> "AO Phone <br /> 7 s VA2 W11—e— k!7 License No.44; <br /> Contractor _1d1ffLWA Address r,, <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT El DESTRUCTION F-1 <br /> PUMP INSTALLATION W onj5A17— SYSTEM REPAIR 0 OTHER El <br /> — <br /> DISTANCE TO NEAREST-. SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> IJ Industrial 0 Open Bottom [5 Manteca Di,. of Well Excavation— <br /> 0 Domestic/Private D Gravel Pack D Tracy Type of Casing I Specifications <br /> Ll Public I] Other C Delta 'Depth of Grout Seal Type of Grout <br /> 0 Irrigation ---Approx. Depth D Eastern SN ace Seal Installed by <br /> Repair Work Done C1 Type of Pump H.P. a State Work Done I tVS7,Vz1= <br /> Well Destruction LI Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJ REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units:— Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well Foundation— Prop" Line <br /> I. <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well Foundation— Property Line <br /> SEEPAGE PITS Ll Depth Size y Number <br /> i.SUMPS 0 Distance to nearest: %.Well Foundation Property Line <br /> DISPOSAL PONDS F-I <br /> d that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application an <br /> rules and regulations of the San Joaquin Local Health District. <br /> certify that in the performance of the work f6r which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I <br /> employ any person in such manner as to become subject to workman's compensation laws of Calif ornia ContrAct <br /> or's hiring or sub contracting signature <br /> my persons subject to workman's compensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall emplo <br /> tion laws of California." <br /> The appli <br /> leant W2 all re ons. tompl <br /> nspectiete drawing:on revers e.'0 <br /> o <br /> Signed X- Date: <br /> L I <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by- Date <br /> —,-Additional-Comments:, <br /> 0 Stk 466-6781 El Lodi 369-3621 0 Manteca 823-7104 Tracy' 835-6385 <br /> Applicant= Returh all copies to: Environmental Health Permit/Servicas 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9601 <br /> CKL4; "NO.' <br /> FEE AMOUNT DUE AMOUNT REMITTED CAjS*H " RECEIVED BY DATE PERMIT <br /> INFO <br /> + EH 3-24(REV.1/8 5) -7 SS <br /> EH 1 <br /> 14-26 <br />