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,/..�.....e�--- .. 4 <br /> i <br /> APPLICATION FOR PERMIT �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—t ON AVE., STOCKTON, CA 3 <br /> Telephone {209) 466-6781 <br /> .PERMIT EXPIRES 1-YEAR'FROM DATE'ISSUED 9 ` <br /> ! Y (Complete in,Triplicate) if <br /> r P w lication is <br /> Application is hereby made to the San Joa}quin Local Health District for a permit to construct and/or install the work herein described.This app y <br /> sewage or No. 1862 for welllpump and the�Rtfles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for <br /> Local Heal#Fi District. <br /> 4 �O'L <br /> I1cl f.7t •� 1{pCity �+4 Loi Size alYf PM r <br /> Job Address <br /> f • rAddes3 ;?hone <br /> Owner's Name-AL, <br /> r <br /> �! / pC 2 r <br /> Q l� Ww� rA s -7 g7 b ilR � License No.�7 J_ �= Phone, J 7=��3, ». <br /> Contractor <br /> x,�TYP,E­OF WELL/PUMP:�'"� R' N WELL WELL REPLACEMI= I DESTRUCTION ❑ �. <br /> r PUMP INSTALLATION 1:1s q SYSTEM REPAIR ❑ 9 F OTHE <br /> --SFA <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. 'LINE a .d1 <br /> r <br /> - PITS/SUMPS <br /> L3LfER WEL AGRICULTUjRE WELL OTH <br /> irr - T „ FOUNDATION <br /> V t4 <br /> " <br /> rs� v..,r.5 <br /> INTENDED USE 3- TYPE OF-WELL PROBLEM AREACONSTRUCTION SPECIFICATIO " �1 <br /> ❑;IndustPial' Cl Open Bottom — ❑ Manteca } <br /> Dia. of Well Excavatioh NDia. of Well Casing <br /> —t k'' S S ecifications O ! <br /> Domestic/Private r' ❑ Gravel`"Pack•;:t ❑ Tracy 7ype'of Casing ; <br /> t❑ Other 1 t.. v' ❑ Delta Depth of Grout Seal Q '� Type of Grout 9 <br /> F-1 Public �. 1 l r <br /> ❑ Irrigation 1 -APprox'. Depth ❑ Eastern Surface Seal Installed by <br /> r e +e <br /> State Work Done <br /> Repair Work Done ❑ pNType;ofF Pu H.P. <br /> Well Destruction ❑ Well Dianne Sealing Material 50'1 <br /> i r I Dept Filler Mater; elow;50'1 <br /> :I TYPE,OF SEPTIC WORK- NEW INSTALLLATION ❑ REPAIR/ADDI ION ❑ DESTRUCTION ❑ availabllelwit in 200 feet.)permitted if public sewer is <br /> 1 Installation will serve: Residence_ 'Commercial Otfier <br /> k Number of living units: `Number ofbedroom <br /> F i Water table depth # <br /> Character of soil to a depth of 3,feet :i` - .R <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg j Method of Disposal <br /> PKG. TREATMENT PLT.-F] <br /> �"" """ _ 1 <br /> I Distancetto nearest: .f Well Foundation Property Line <br /> ! ' Total length/size <br /> LEACHING LINE ❑ No. & Length of line <br /> i FILTER BED ❑ Distance to near Well Foundation Property Line s. <br /> :7 <br /> Number i. <br /> SEEPAGE PITS ❑ Depth . I <br /> SUMPS ❑ Distance to neores Well Foundation Property Line <br /> DISPOSAL PONDS ❑ j. <br /> 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 shall not <br /> employ any person in such manner,as to become subject to workman's compensation laws of California." Contractors hiring or sub contracting signature <br /> l certifies the follo iri '"I cerflfy that in the performance of the work for which this permit is issued�l,shall employ persons subject to workman's compensa- <br /> tion <br /> laws of <br /> Ca' <br /> Th.a applican s a require spec; mplete drawing on reverse side. 1, <br /> Da ! <br /> Sigh.0d itle: <br /> FOR IDEPARTMENT`USE ONLY <br /> DatArea <br /> Y. � e � <br /> Application Accepted by <br /> Pit o Gro t Inspection by <br /> f ' Dat "'� Final inspection by r Date <br /> ` Additional Comments: <br /> ❑ Stk 466-6781 0,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. Box 2009, Stk., CA 95201 <br /> FEE CK#. _ RECEIVED BY DATE PERMIT''NO. <br /> g' <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> � l - <br /> �`.. + EH 13-24(REV.1/85f <br /> EH 14-26�. Q <br />