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A. <br /> APPLICATION FOR PERMIT 3 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E.4HAZELTOWAVE:, STOCKTON, CA <br /> Telephone(209) 466-6781 <br /> PERMIT EXPIRES 1 YE R 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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Nam 14dressA Phone ✓ <br /> `I t � j <br /> Contract d✓< dress ' License No._� r1_ Phone <br /> &Vce_ <br /> TYPE OF WELL/PUMP: NEW WELL F1WELLIkEPLACEMENT 171W w DESTRUCTION ❑ ! : <br /> PUMP INSTALLATION 171SYSTEM REPAIR O OTHER ❑ � <br /> DISTANCE 70 NEAREST: SEPTIC TANK I SEWER LINES �,,? ._� DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTPRE WELL. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL j PROBLEM AREA CONSTRU. TION SP,CIFICATIONS l <br /> ❑ Industrial ❑ Open Bottom 1 ❑ Manteca Dia. of W41Mcavati don Dia. of Well Casing <br /> ❑ Domestic/Private LJ Gravel Pack t ❑ Tracy Type of Casing „ Specifications <br /> i <br /> ❑ Public ❑ Other = ❑ Delta Depth of Grout Seal 1 Type of Grout <br /> ❑ Irrigation ---Approx. Depth Q Eastern Surface Seal-Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ` Sealing Material (top 501 <br /> r 4J f <br /> Depth I Filler Material,(Beiow 50') r-- - — - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ,REPAIR/ADDITION ❑t DESTRUCTION 171iNo septic system permitted if public sewer is <br /> ' >11� 9 V available within 200 feet.)' <br /> Installation will serve: Residence Commercial,- Other i E-4 <br /> Number of living units: Number of bedroom`s' l ' <br /> Character of soil to a depth of 3 feed Water tab)@&pth �3 I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �+ <br /> PKG. TREATMENT PLT. Q t " Method of Disposal _j, <br /> Distance to nearest: I-Well I Foundation Property 4ine' <br /> LEACHING LINE WINo. &Length of'linesWJ ( Total length/size 1 <br /> FILTER BED Lles <br /> Distance to neart: 7,Well\ I Foundation r+-✓ProprtyLir1'b. ) Nlje <br /> SEEPAGE PITS Depth .Siie'- � ' Number <br /> SUMPS E3 Distanced to nearest: Well Foundation '� Property Line - 1 <br /> DISPOSAL PONDS ❑ <br /> I hereby certify tliat`sl have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state'-laws, and <br /> rules and-Tegulations`of the San Joaquin Local`Health District. <br /> Home•owneF of-lite#:§ad'age t' signature certifies the following: "I certify that in the performance of the work'for which this perrtii is issued, I shall'not-' <br /> employ any person in such nner as to become subject to workman's compensation laws of California."Con`tractor's hiring or sub-contiacting siJnature <br /> certifies the following: "I ify that in`the perfo� an a work for which this perinit is issued;"I shall employ,persons subject to workman's compensa- <br /> tion laws of Californi f e ' <br /> The ap for all <br /> requ' to ng on�r. ...Signed i Title } '�,' Dettee-. - {a <br /> ell- Z <br /> DEPAR MENt USE ONLY <br /> Application Accepted by Date ' '. » Area <br /> F Il <br /> L �Y��Final <br /> it Grout Inspection by Date Inspection by Date <br /> e'YD Ge'lil¢ -b. 9 <br /> Additional Comments: <br /> Cl Stk 466 6761 I todi 369-i621 ❑ Manteca 823 7104 t ❑ Tracyos�+.ziv Q,by. <br /> Applicant- Return all copies to: En it}o}nments Health Permit—/.S)" 1601:E. Hazelton Ave.;,P.O.' Box` Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED ; CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH 13-24(REV.)/5 5) 3py <br /> EH 14-25 <br />