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APPLICATION FOR PERMIT
<br /> SAN JOAQUIN LOCAL HEALTH DISTRICT
<br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA
<br /> Telephone (2091466-081
<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 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 Ryles and Regulations of the San Joaquin
<br /> Local Health District.
<br /> Job Address `� 44�[� City c "*� Lot Size PM
<br /> ir
<br /> Owner's Name k � D �Address Phone f
<br /> Contractor Address '�� '-� 't/ License No. Phone
<br /> 4 .T—e
<br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑
<br /> c „�,�,-_,,,„„�,,,,,,,,,,_,,,,,,�,PUMP INST_ALL_ATION- ❑ w,,,o,,,,,�_„_,,,SY$TEM,�REP,a,�F�,,,q,,,,,��, OTHER Cl _
<br /> DISTANCE TO NEAREST: SEPTIC TANK y SEWER LINES DISPOSAL FLD. {PROP:"LINE
<br /> FOUNDATION AGRICULTURE WELL OTHER WELL \\PITS%SUMPS;
<br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,
<br /> I. ❑ Indust pial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dim of Well Casing
<br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing aSpecifications
<br /> ❑ Public i 'tai.y —S-Other D Delta Depth of Grout Seal Type of Grout
<br /> ❑ Irrigation 04- 'Y�L>lpprpx.`Depth D Eastern SurfaceZ Installed by i
<br /> - s6 .-. fY.
<br /> Repair Work Done ❑3 Type of Pump z� �,,} 41- State Work Done
<br /> Well Destruction ❑I 'W i=f3iameter ASeaf:ng Meat nq }tpp_.iD'}�� w-- -a
<br /> Z ; ri leer/lila afiB fcjlw�50'1
<br /> TYPE OFISEPT19:-WORK: NEW INSTALaTION R P CIR/A'bDIT10N.,1] iDESTRUCTION ❑ I(No septic system permitted if public sewer is
<br /> available within 200 feet.) F}
<br /> Installation will serve: Residence Commercial Other )
<br /> Numbeer of living units: Number of;bedrooms
<br /> Charac er of soil to a depth of43�f et ^+t'"R i 'c= , Water table depth
<br /> SEPTIG.` ANK Type/M gity No. Compartments 2f,
<br /> PKG. TTATMENT PLT: D �tb�r � E7Z7� Method of Disposal
<br /> Distance to neai:Qst: Well- � Foundation Property Line
<br /> LEAC_HING„LINf No. & Length of lines ' ;L— 0 ryyd
<br /> s .r- g � r. {.�- ..-.T�I�el�gth/size
<br /> FILTEWBED *nl Distance to nearest: Well Found9rtion Property Liner
<br /> SEEJPAG9 PITS Depth Size VrtNumber
<br /> 3
<br /> g.. ��
<br /> I
<br /> SUMPS'p ❑ .Distance to nearest: Well Foundation�ZU ! �roperty Line
<br /> 3 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 andfegulations of San Joaquin Local Health District. '
<br /> Homefoltiner or Iic d age 's signature certifies the following: "I certify that in the performance of the work for which this permit iI issued, I shall not
<br /> ` employ any pe in such rr ner as t become subject to workman's compen'ha ' n.laws ofPCalifori.'i ." Contractor's hiring or sub-contracting signature
<br /> f certifies the f owing:"I certi at i e performance work for whic3fi his p mit is issi Ad,jl shalkemploy persons subject to workman's compensa-
<br /> tion laws#of alifornia." A
<br /> The applican must c r q ed ins c pl to drawing og. side. d`
<br /> + .�
<br /> Signedrtle: IDate:
<br /> FOR D£PA'RTMEI�IT]USE OI /' )
<br /> Application ceptecl�by i 'A �'Qe$®-v
<br /> 7 F�SJ Final I$ ectionr + Date
<br /> it r Grout Inspection by Date
<br /> :l p _y'_
<br /> Additional Comments: ��< < 5 d a w 4 t �R+° /�i 5' 3 5-
<br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 1 ❑ Tracy 5-6385
<br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201
<br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0
<br /> CASH RECEIVED BY ! DATE PERMIT'NO.
<br /> + EH13-24IAE1l.7/e51
<br /> EH 1426 yJ �� `p(3 /7S sS�5��
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