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a � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED <br /> rr (Complete in Triplicate) <br /> ct and/or <br /> cation is <br /> Application is hereby made to the San uin Caun JoaquinOrdinance No.Local Health D549 for for <br /> or No. 1862 for well/pump install <br /> nd he Rules and herein <br /> described. <br /> offtthe Sa 1 Joaquin <br /> made in compliance with San Joaq tY , <br /> F Local Health District. , r , <br /> P <br /> , r � M <br /> Q „E, City Lot Size <br /> Job Address <br /> Phone <br /> Owner'sOwner's Name Address Q 1 <br /> License No 2 Phone <br /> MP: NEW <br /> '� � [f <br /> Contrac Address DESTRUCTION ❑ <br /> TYPE OF WELL/PU � WELL F1 WELL REPLACEMENT 71It OTHER ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS �+ <br /> 1 FOUNDATION } �' AGRICULTURE WELL r iz <br /> INTENDED USE I;TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Domestic/Private 11 Gravel Pack ��""❑"Tracy"' t a <br /> C] Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Public <br /> Surface Seal Installed by <br /> ❑ Irrigation Approx. Depth ❑ Eastern <br /> H.P State Work Done <br /> -,-Repair Work Done 11 Type of Pump ¢ <br /> Well Destruction Ll Well Diameter ; - Sealing MateriA (top 511 <br /> Depth. y Mer Material (Below ') <br /> TYPE OF SEPTI— 'NEW INSTALLATION. REPAI ADDITION DESTRUCTION ❑ (No llseptic le vshste��f Bitted if public sewer is <br /> � ly <br /> - ° <br /> Installation will serve: Residence Commercials Other, f <br /> !� <br /> Number of living units: 't Number of drowns eater table depth <br /> C' Character of soil to a depth of 3 feet: o.7 �7 — o Compartments <br /> SEPTIC TANK I!�/TVpe/Mfg �E' <br /> .h , -- - Method of Disposal <br /> PKG. TREATMENT PLT. d, I V i, t� <br /> ine <br /> I1Distance to nearest: Well Foundation Property L <br /> •q l t <br /> X2- <br /> r• '� �- Total length/size <br /> LEACHING LINE INo. & Length of lines _ <br /> „ / <br /> FILTER BED y© Distance to nearest: Well KOO— Foundation Property Line <br /> t� <br /> i { Depth Size` '_ , r. Number <br /> SEEPAGE PITS <br /> I. Distance to nearest: Weld Foundation Property Line <br /> - <br /> SUMPS <br /> DISPOSAL PONDSand <br /> cL7 y` <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, <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 shall not <br /> amply 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: uI certify that in <br /> s the performance of the work for which his permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California. '1 <br /> The applicant m call;for'"ll ire inspections. Complete rowing on revere . <br /> �� , Date <br /> Signed <br /> r i Title. ` _ <br /> _ <br /> � FOR DEPARTMENT USE ONLY <br /> * '!- Date Area <br /> Application Accepted by2 <br /> i 1^ [ Final Inspec"tion by Date <br /> Pit or Grout Inspection by 'pate f f <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-3621 ,1 ❑ Manteca 823-7104 ❑ Tracy 8�5-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601-E. Hazelton Ave>,P.O. Box ZQ09;StkiCA 01 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> IFEE <br /> NFO IfAMOUNT DUE '- AMOUNT REMITTED CASH <br /> i� g goo^t 063 <br /> + EH 13-24(REV.v/a 67 <br /> EH 1426 <br />