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EJ y <br /> APPLICATION FOR PERMIT � <br /> I, <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> No LJ ALL <br /> 1601'E..HAZEITON-AVE." STOCKTON, CA <br /> Telephone (209) 466-6781 ND p`,4, o N i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> `,. (Complete in Triplicate) <br /> all the work <br /> ed.This <br /> n is <br /> Application is hereby made to the u n Countyn Local Health ordinance No'D549 for for <br /> or No. 1862 forcwell/dpump atnd the Rules and herein <br /> Regu�lations of the San Joaquin <br /> u n <br /> made in compliance with San Joaq tyI <br /> Local Health District. 0 " <br /> ,S i City Lot Size PM <br /> Job Address _ <br /> 17z-._- - <br /> (,f-1 <br /> dress - v.2 �,L Qe!//.S Phone <br /> Owner's Name �Ox <br /> - — <br /> Address ' License No.- Phone <br /> Contra ctor <br /> TYPE;OF WELL/PUMP: NEW WELL 114 WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION .❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER ES <br /> �H�ERWELL <br /> L FLD. PROP. LINE <br /> I FOUNDATION AGRICULTU WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON UC SPECIFICATIONS Dia. of Well Casing <br /> 1-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Excavation <br /> T of Casin Specifications_ rr <br /> p Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout 1 <br /> [D Public ❑ Other ❑ Delta Depth of Grout S <br /> O Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installs y <br /> H.p State Work Done— <br /> Repair Work Done ❑ Type of Pump <br /> Destruction EIWell Diameter Sealing Material {top 50'} <br /> ! <br /> 111 Filler Material (Below 501 <br /> Depth <br /> `�TYPEAOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION available wittic hin 200 feet.) if public sewer is <br /> r 1 <br /> _Other — e -•�_ - <br /> i Installation will serve: Residence Commercial. . -_..�,� " <br /> Number of living units: / Number of bedrooms 17, <br /> Water table depth <br /> � } Character of soil to a depth of 3 feed <br /> . i CapacityNo. Compartments <br /> w SEPTIC TANK ❑I TypelMfg <br /> Method of Disposal <br /> PKG.jREATMENT PLT. ❑ Property Line <br /> ---�� Distance'to nearest. Well Foundation <br /> E Total len th/size <br /> LEACHING LINE ❑ No.`& Length of lines! g <br /> S € Foundation Property Line <br /> Elce <br /> FILTER BED - Distanto nearest" Wetl <br /> k ❑ DeNumber <br /> € SEEPAGE PITS Depth Size <br /> SUMPS - ❑ Distance to nearest: Well Foundation Property Line <br /> l DISPOSAL PONDS ❑ <br /> 1 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 /> Homeowner or licensed agent's sign "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ature certifies the following: <br /> empty 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 fo I :""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 /> I tion laws o alrforrna." <br /> The applic nt u call for all required in ctionipp. completegdrawing on reverse side. <br /> Iitle: Date: <br /> igned , <br /> ! FO PARTMENT USE ONLY <br /> Date Area <br /> j Application Accepted by y <br /> Pit or Grout Inspection by <br /> Date Final Inspection by F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 El Tracy 835-6385 <br /> lth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Hea . <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED A RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24[REV.t/8!j) <br /> EH 1429 <br />