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S � <br /> Uv­ r APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT PAY ErIT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 11E G E i V E D <br /> Telephone {209) 466_6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV 131987 <br /> iComplete in Triplicate] <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work � H fcaLpon <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R ]Joaquin <br /> is <br /> Local Health District, <br /> I?Q+r`01W*t S#orrx TVU70no_C I W..Wa.ohitl5fon S{ . $, Ncwy I)rik- <br /> r r I <br /> Job Address P^�^�r9� or I��/1 City-- S�oC.L. k1 Lot Size 9400 X Ib00 PM <br /> Owner's Name h5r+ 0; �„51QLk'}-C1Y1 Address Phone <br /> ,f,.2390 <br /> Contractor Address I t p License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> is <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE 1D0 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 16, fni Ia✓ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation141 <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing VC Specifications <br /> ❑ Public X Other ❑ Delta Depth of Grout Seat St Type of Grout l <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by [ <br /> Repair Work Done ❑ Type of Pump NQ13eH.P. State Work Done <br /> Well Destruction ❑ Well Diameter 411 Sealing Material (top 501 i <br /> Depth ' SO Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION p REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is l <br /> available 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 ❑ Type/Mfg CapacityNo. Compartments y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 0 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 shalt 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 taws of Californ' .' y <br /> The applicant all for all req ns. Complete drawing on rever de." <br /> Signed Title• <br /> Date: ��� <br /> / ' i <br /> FO AE U Y <br /> Application Accepted by r Date Area <br /> Pit or Grout tnspecti b 1P" <br /> Date Z 7r Final Inspection by c q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ T,1icy 83&6385 <br /> Applicant• Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2pt)9, tk., CA 962p Y `t <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED 13Y <br /> INFO DATE PERMIT'NO. <br /> • EH 1324iREV.I/a5) <br /> EH 14-26 <br />