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APPLICATION:FOR PERMIT M <br /> SAN JOAO,UIN,LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE., STOCKTON, CA 07`' <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) .. <br /> hcation is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This app 1 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and R eegula �nsOof the Joaquin <br /> Local Health District. k. <br /> ._ o.�s- '�'. f <br /> %44 LL t�(.JP6 city Lot Size 3 j dPk . ,PM <br /> Job Address <br /> _ Address + u T Phone <br /> Owner's Name -Ly (C ft - d-7 1 <br /> +_ die v�-ON w e I 1 PhonAIS 9 l'! �ici� <br /> Contractor's Name J64 - - License No. <br /> NEW WELL ❑ <br /> WELL REPLACEMENT ❑ DESTRUCTION El -7��-+ ' i _ L e� <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 11OTHER� <br /> PUMP INSTALLATION ❑ � $ � <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE tit d} <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL FITSISUMPS <br /> 2U <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type <br /> of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout <br /> C] Public ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Sealing Material (top 50'] <br /> Well Destruction ❑ Well Diameter g , <br /> Depth Filler Material (Below 501 <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (NoIsepticable within permitted if public sewer is <br /> avaInstallation will serve: Residence— Commercial, Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK t ❑ Type/Mfg capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line \ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ 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 shall not <br /> r 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 laws of California." <br /> The applic t must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEP RTMENT USE ONLY <br /> Date �illf � Area <br /> Application Accepted by <br /> final Inspection by C- �^ Date <br /> Pit Grou nspection by Date / — <br /> Additional Comments: ' dt <br /> ❑ Stk 466-6781 ❑ Lodi 369- 1 d Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE <br /> ffCK RECEIVED,BY DATE1FEEAMOUNTDDUE AMOUNT REMITTED <br /> NFO <br /> +EH 13.24(REV.10183) y/ _ <br /> EH 14-26 <br />