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E3 <br />.1 m .T+, - <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 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />ll the work <br />n desc <br />Application is hereby made to he San u n County wcation is <br />OLd Hance No. District549 for sewage or permit <br />1862 for cwell/ pump t and/or and the Rules and (Regulations of he Sant Joaquin <br />made in compliance. with San Joaq tY <br />Local Health District. <br />,•I Q "r C,ty <br />Lot Size PM <br />Job Address L <br />Phone <br />Owner's Name � Address <br />Pflone <br />y <br />01 <br />Contractor's'Name- y WELL REPLACEMENT ❑� DESTRUCTION 13TYPE OF WELL/PUMP: NEW WELL . OTHER CD <br />PUMP iNSTALLATION ❑ SYSTEM REPAIR ❑ <br />SEWER LINES �— DISPOSAL FLD. PROP. LINE <br />DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br />FOUNDATION AGRICULTURE WELL OTHER.WELL <br />INTENDED USE _ TYPE_OF WELL BLEM AREA CONSTRUCTION SPECIFICATIONS Dia. -of Well Casing <br />❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ <br />❑ industrial Specifications <br />F-1 Domestic/ Private C] Gravel Pack ❑ Tracy Type of Casing <br />Depth of Grout Seal Type of Grout <br />❑ Public ❑❑rou <br />Other � <br />Delta <br />=�pprox. Depth ❑ Eastern Surface Seal Installed by <br />❑ Irrigation , State Work Done <br />Repair Work Done ❑ Type of Pump H.P. <br />1Z 117 <br />Sealing Material (top 50'1 <br />Well Destruction ❑ Well Diameter �� Filler Material (Below 50'} • - <br />Depth <br />TYPE OF SEPTIC WORK: NEW INS `ALLATION 13 REPAIR /ADDITION DESTRUCTIQN ❑ aNailablelwithin 200 feettted if public sewer is <br />F <br />Installation will serve: 'Residence Commercial } Other r <br />Number ofdiving units: Number of bedrooms a Water t ble depth _ <br />Character of soil to a.depth of 3 feet: f '. T No. Compartments <br />SEPTIC TANK E] Type s Capacity Mfg Method. of Disposal <br />PKG. TREATMENT PLT. ❑�,T1 Property Line <br />? Distance to nearest: Well Foundation <br />LEACHING LINE <br />FILTER BED <br />I <br />No. & Length of lines <br />/ ❑ Distance to nearest: <br />Waft � Foundation <br />` Total length/size " <br />OL <br />'Property Line, <br />I tis j <br />Size= Number <br />SEEPAGE PITS ..❑.-,.Depth. - r <br />Foundation Property <br />SUMPS El 'Distance to nearest: Weil <br />DISPOSAL PONDS ❑ <br />I herebycertifythat 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.ch <br />Home owner or licensed <br />ice insuchen manl not <br />ner tobecomesub ecte certifies theolto workman'srtcompensat on lify that in the awsofCaliforrnia." Contraotance of the work r's1hiringl orr sub -contracting signature <br />employ any pe rsons subject to workman's compensa- <br />certifis the following: "I certify that in the performance of the work for which this permit is issued, I sFiall employ pe 1 <br />tion laws of California." F =f , <br />The applicant must -call for -al equired inspections. -Complete drawing on ieversereide. <br />T <br />Signeds '- <br />°+'��� ` FOR PARTMENT USE ONLY j {� <br />- {• Date `� —?r • !V Area <br />Application Accepted by <br />pate <br />Pit or Grout Inspection by •Date.��-- Final lnspectian by <br />Additional Comments: ` - <br />❑ Stk 466-6781 ❑ Lodi 369-3621 eco 823 7100. El Tracy 835 0—, <br />En <br />Health Permit/Services 1601 E. Hazelton Ave., P.O. Box <br />Applicant -Return all copies to: E 2009, Stk., CA 95201 <br />FEE CASH RECEIVED BY. �. s rDATE PERMIT 'NO. <br />AMOUNT DUE AMOUNT REMITTED CK m ti . . <br />+ <br />E14,113-24 IREv. 10!831 �"� S. O,11N , <br />LW 5i2B _ _ <br />R <br />001V47v <br />