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APPLICATION FOR PERMIT -� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYW FN r <br /> E. HAZELTON AVE., STOCKTON, CA <br /> 1 f301 E RECEIVED <br /> Telephone (209) 466-6781 <br /> " PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAR 14 19P <br />� (Complete in Triplicate) the <br /> AdhlalR(HD0�#MtqteN�1t,{A�1�hid [i1tWon is <br /> Appt�1VlI I jCKY� it Joaquin <br /> ade to the San <br /> uin <br /> ealth District for a <br /> i <br /> madlec in compliance with h San Joaquin County ordinalncle No.549 for sewage o permit <br /> No. 1862 forconstruct <br /> well/and/or <br /> pu well/pump and the Rules an lyt <br /> Local Health District. <br /> ? Z. $ S S O IN. t CityK� M <br /> Lot Size 1lW '1r - ' PM <br /> Joh Address <br /> F <br /> Address <br /> 8 _ Phone,20 B3 <br /> i Owner's Name G,, <br /> E � �Phone�'���� <br /> j Contractor��5� <br /> I Addresses � 6C License No.SS_ <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI <br /> TYPE OF WELL/PUMP: OTHER h4 Got2t 7L <br /> �•1/�i�5 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ r <br /> aoe� r SEWER LINES bol DISPOSAL FLD.I`�� PROP. LINE <br /> i DISTANCE TO NEAREST: SEPTIC TANK o 1 (� �,� �,lP JIT. <br /> FOUNDATION O� AGRICULTURE WELL — OTHER WELL PITSISUMPS L- <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE <br /> t N— O it— Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom 13Dia <br /> Manteca . of Well Excavation — <br /> Type of Casing _W N Specifications / <br /> ❑ Domestic/Private ❑ Gravel Pack L[1 Tracy Yp �,Q p�,� Type al Gra L11`44"—'~ '� <br /> f`I Public f1 Other' fl Delta Depth of Grout Seal `zs <br /> I I Irrigation 645!Approx. Depth I I Eastern Surface Seal installed by <br /> r.. <br /> Type of Pump er H.P. 1�.� State Work Done _ <br /> Repair Work Dane U Typ V1 <br /> Well Destruction O Well Diame er Sealing Material (top 501 � o <br /> ! <br /> Depth � _ Filler Material (Below 50'1 <br /> ! <br /> i <br /> TYPE OF SEPTIC WORK: NEW IN TALLATION I I REPAIR/ADDITION I I DESTRUCTION I I aNailablerwi[I rn 200 leetllccl if public sewer is <br /> Installation will serve: Residence— Comme ial Other �I <br /> Number of living units: Number of bedroo , 1 <br /> Water table depth +" <br /> Character of soil to a depth of 3 feet. <br /> SEPTIC TANK Ll Type/;tonearest: <br /> <Fo <br /> No. Compartments y <br /> ` PKG. TREATMENT PLT.❑ Method of Disposal vr[i <br /> DistanProperty Line <br /> LEACHING LINE ❑ No. & inesTotal lengthlsixe <br /> FILTER HED D Distanst: WeProperty Line �{ <br /> I <br /> Number <br /> SEEPAGE PITS 11 Depth Size — <br /> F SUMPS C1 Distance to nearest: Well Foundation Property Line �1 <br /> i J <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 /> i rules and regulations of the San Joaquin Local Health DiUrict. <br /> j 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 compansa- + <br /> tion laws of California." <br /> The applicant must call for II required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title:Q r2 `N , Data: — g <br /> 1`05TMENT USE ONLY <br /> t� <br /> r Application Accepted by ter" '� Date--- Area <br /> Pit or Grout Inspection by <br /> Data Final Inspection b Date <br /> Additional Comments: � <br /> ❑ Sik 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 t� r r JA <br /> FEE <br /> F RECEIVED BY DATE PERMIT'NO.INFO AMOUNT DuE AMOUNT REMITIED ,1 1 (� / U AL <br />