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APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRI'CT61' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ., <br /> S <br /> (Complete in Triplicate} <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 application is <br /> € made in compliance with San Joaquin County Ordinance No fore wage or No. 1862 for well/pump and the Rules and Regulations f the San Joaquin <br /> � <br /> Local Health District. ���" <br /> t Job Address - 1/' , 6; r /City Lot Size PM r <br /> I- <br /> f Owner's Name ddress lig ne <br /> 4 Phone <br /> Contractor �tt Address License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER F' <br /> 1 } DISTANCE TO NEAREST: SEPTIC TANK _- SEWER LINES I DISPOSAL FLD. PROP. LINE - E <br /> FOUNDATION -- AGRICULTURE WELL OTHER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial El Open Bottom ❑ Mantes Dia. of Well Excavation Dia. of Well Casing ; <br /> D Domestic/Private ❑ Gravel Pack ) <br /> Q Tracy `� t Type of;Casing Specifications <br /> 7 Public ❑ Other � El !) Depth of Grout Seal Y Type of Grout r <br /> Irrigation _-Approx. Depth C] Eastern ns <br /> Surface Seal Italled by__ _ ) t <br /> Repair Work Done 171 Type of Pump % H.P.. I _ State Work Done <br /> { <br /> Well Destruction ❑ Well Diametei ` <br /> { � Sealing Material(fop 50'1 .- <br /> DepthL Filler Material (Belo_ 501 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q 'REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is �ry <br /> t <br /> available within 200 feet-) I+ <br /> Installation will serve: Residence _ Commercial_ Other <br /> a t <br /> Number of living units: Number of bedrooms _ r <br /> Character of soil to a depth of 3 feet:;._.. Water table depth <br /> SEPTICtTANK ❑ Type/Mfr ' <br /> t g' Capacity_ No. Compartments <br /> a ° PKG. TREATMENT.PLT,. ❑ AMethod of Disposal" <br /> - - Distance t# nearest: a'WeII Foundation _ Property Line_-_ i <br /> LEACHING LINE F LJ•'No. 8 Length of lines Total length/size t ' <br /> FILTER BED ❑ Distance to nearest: W o Property Line <br /> rI1 <br /> SEEPAGE PITS i '❑ Depth b Size --Number r k <br /> SUMPS i C Distance to nearest: Well Foundation X8 T Property Line <br /> ! DISPOSAL PONDS' ❑ i r <br /> I hereby certify that I have prepared this 6 pplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and i <br /> rules and regulations of the San Joaquin Local Health District. 1 <br /> , <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 Cal-ifomia."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." R <br /> The applies t must call for al�uired i spections. Complete drawing on reverse side. f <br /> t Signed _ Title: Q _ Date: U {7 F <br /> FOR R DEPARTMENT USE ONLY <br /> anon <br /> Accepted by Date Area d. <br /> } <br /> Pit" Grout Inspection by ' Date JL 2 Final Inspection by Date <br /> Additional Comments- <br /> '0 <br /> omments:'O Stk 466-6781 ❑ Lodi! 369-3621 q Manteca -823-7104 ❑ Tracy 835-6385 •, <br /> r <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O.,Box 2009, Stk., CA 95201 <br /> .FEE ) r r F <br /> INFO AMOUNT DUE -� � AMOUNT REMITTED CASH RECEIVED BY DATE PERMR NO. <br /> rEH1429 �3-2r(REv.,igs) <br /> EH 1 I ­76,. d� ........ ..�...- Yt �/SL <br /> ��C7 <br />