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«,. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> } Telephone (209) 466-6781 <br /> , PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> . (Complete in Triplicate) <br /> cribe <br /> is <br /> cation is <br /> made in complitance wereby ith Sanade o the Joaqu n County Ordinanuin Local cle No.549 for sewage ealth District for a or 1No. 1862 forconstruct <br /> well/and/or <br /> pump and the Rules and herein <br /> R Regulations of tthe Sans Joaquin <br /> Local Health District. <br /> 1 [ }�Q" <br /> �7 Z i,^ City Lot Size 1X33 PM f <br /> Job Address _. — <br /> Owner's Name <br /> u�' P Obi. Address �- Q C�S d5 Phone 0 <br /> Contractor <br /> M1 I Address License No. Phone r <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ ° <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTOAE=WELL. ti �-"OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA 'CONSTRUCTION SPECIFICATIONS v <br /> E) Industrial ❑ Open Bottom C1 Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public f7 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> { <br /> I I Irrigation _..Appro>< Depth t I Eastern Surface Seal Installed by - <br /> r H P. <br /> State Work Done _ W <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 ' <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION ! I DESTRUCTION (No septic system petmitted if public sewer is <br /> available.withih"200 feet'.)., <br /> Installation will serve: ,Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feel-1.* - -r" ` Wat-6f-table depth _ r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I` PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> f Distance to nearest: Well Foundation Property-Line <br /> Total len th/size 'R <br /> LEACHING LINE [I No. & Length of lines 9 <br /> FILTER BED ❑ Distance to nearest" Well Foundation Property Line <br /> II s <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> IIr DISPOSAL PONDS ❑- F <br /> I 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 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." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I c ify that in the perfo nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws"of California." f <br /> The applicant m t call or II require i cf s. Complete drawing on reverse side. <br /> 7-0 <br /> Signed X y Title: : rte• Date: f <br /> FOR A . ..T USE ONLY c4—,l 7 <br /> 4— /,+T��U <br /> Application Accepted by Date ea <br /> Pit or Grout Inspection by Date Final Inspection b Date r <br /> Additional Comments: <br /> ' ❑ Stk 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.Q..Box 2009, Stk., CA 95201 <br /> FEEE!791 <br /> AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO ``�� �JJ �} 190-qla- <br /> ♦,EH 13-24(REV. /K 51 3 s,L7 V q`1 l-cm EH 14-28 <br />