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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ' <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Hea_ District.for a permit to construct and/or install the work herein described. This application is <br /> 'm'ade-in.compliance with S-any Joaquin Co linty OrdinancoNo.549 for sewage-or,No. 1862 for well/pump and the Rules and Regulations of San Joaquin 3 <br /> Local HeahhWDistrict. t <br /> .. �w1 _ City .� Lot 5`iie'^ <br /> : .,,,- <br /> , r PM <br /> Job Address s� <br /> Mon <br /> e. <br /> Owner's Name <br /> / Address cP�_ — .•-. x-1 <br /> � T, <br /> $ J' rR� `.� yJ /_.f�/��: License No. <br /> Contractor -� ddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> {PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ M1 <br /> DISTANCE TO NEARLSTf SEPTIC TANK SEWER LINES <br /> I DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ] � OTHER WELL PlT51SUMP5 <br /> INTENDED USE } : TYPE OF WELL PROBLEM AREA CON STRUCTION,SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationy <br /> Type of Casing <br /> 1 1 Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack fl Tracy• yp 9 <br /> I'1 Public IF] Type of Grout Other 1-1 Delta DepthFof Grout Seal , <br /> I Irrigation f �.Approx. Depth l I Eastern Surface <br /> Seal 1 stalledby � .� <br /> Repair Work Done ❑� Type of Pump iT H•P- F State Work Done <br /> Well Destruction ,Well Diameter Seeking Material;{top 50'1 <br /> r! <br /> I'Depth ' Filler Material {Below 501) <br /> TYPE OF5EPTIC W..ORK:p NEW INSTALLATION Il REPAIR/ADDITION 1,1 DESTRUCTION I i available+wthin 200 feetstem .) if public sewer is <br /> installation will serve: Residence J Commercial.— <br /> Other I <br /> Number of living units: Number_of,bop Ek �,,, . <br /> Character of soil toga depth of 3 feet: <br /> i +F 3 Water table depth <br /> p Capacity_.�� No. Compartments <br /> SEPTIC TANK ❑ Type/Mf r <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ i <br /> Distance to nearest: Well Foiirnda�tion t} { Property.Line + <br /> fi 1 No. & Length of lines ` Total length/size– <br /> LEACHING LINE l <br /> FILTER BED DistancWto nearest: Well Fo6ndation Property tine <br /> 44 -9 f <br /> SEEPAGE PITS I I Depth . Size $ '" Number <br /> r rz <br /> SUMPS L1 Distance to nearest: Well Foundation yl Property Line <br /> DISPOSAL PONDS ❑ 1 $ <br /> hereby certify that I'have prepared this application and that the work will be done inaccorda nce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the,San Joaquin.L-ocal-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, 1 shall not <br /> employ any person in'such manner as`tc fiecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> ermit is issued, I steall employ persons subject to workman's compensa <br /> certifies the following°"I certify that iii the performance of the work for which"tfi,-p. I I <br /> tion laws of California." f-43'PTI { <br /> The applicant c Lf all requ"red in ctions. Complete drawing on reverse NJ <br /> 'de: 1 <br /> e/�� Title: t <br /> Signed �' ' r <br /> i. <br /> ��, QFORDEPARTMENTUSE•OfVLY$ <br /> t ! +t!! <br /> Data 1 rea p <br /> Application Acceptedlby I j Date/� <br /> 1 <br /> r <br /> Pit or Grout Inspection by F Data Final Inspection by <br /> Additional Comments . a <br /> ❑ Stk 466-6781 ( ❑ Lodi 369- 1 ❑ Manteca 823-7104 ❑ Tracy. '835-6385 <br /> Applicant - Return all`-copies to: Environmental Health Permit/Services 1601;E. HazeitWAve'. P.D. Box 2009, Stk., CA 95201 <br /> I <br /> FEE CK RECEIVED 6Y DATE PERMIT•NO. <br /> q INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ..EH 13-24(REV.+/H 5) <br /> fff EH 14-25 <br />