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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZE i ON AVE., STOCKTON, CA <br />Telephone (2091 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM MATE ISSUi~b <br />(Complete in Trippcate) <br />Atli+r+cation is he+rtlry made to the San J08quin Loca' Health District for a ocriwit to constfuct 2nd -'O( <br />install the wo-k hQ 6lfl descritx d. This application s <br />made in COMPliance witli San .lnaquin County Ordinance NG. `A9 ler suwa e 4r Nu- 1662 for well! pump and the Rules and Rejjulations of the San Joaquin <br />I ocaj Health A'strict. <br />job Address City _�� Lot Size _-, -� PM <br />Q — <br />%� � Address _ (V <br />Owr_? \Phone <br />wr's Name <br />�l.l��r�,/�'3�•.. -� t+ U <br />CoMractdr/✓!"" �J� -.` "Address �'1 J � .—License No:3 $ •? •2 <br />TYPE OF WELL1PUMP <br />DISTANCE TO NEAREST <br />INTENDED USE <br />L) Indust;lal <br />1.1 Domestic,,Prorate <br />r- Puhl c <br />I In dation <br />Repair Work Done (3 <br />Well Destruct on _I <br />NEW WELL 11 WELL REPLACEMENT L DESTRUCTION . I <br />PUNIP INSTALLATION _I SYS'EM REPAIR 1-1 OTHER n 1 <br />SEPTIC TANK _ _._ SEWER LINES — _-- DISPOSAL FLD.— .— PROP. LINE <br />FOUNDATION — AGRICULTURE WFLL OTHER WELL__ _ PITS!SUMPS — <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />LJ Open Bottum <br />GrAvel Pack <br />F1 Othu. <br />__ Approx. Depth <br />Type o! Pu mp <br />Well Diamorer <br />IMP41 — <br />TYPE OF SLPTIC WORK: NEW INSTALLA <br />i� Manteca Dia. of Well Excavation Dia of Well Casing _ <br />L' Tracy Type of Cas+ng _ Specifications <br />71 Delta Depth of 6mut Sbal Type of Grout <br />1 I Eastarn Surface Seal Installed by ._.- <br />_____ <br />H. p. _._ — State Work D,,me <br />Sealing Material (top 511')-- <br />Fil'or Material 18elow <br />N I REPAI !ADDITION 1 D1=S1RUCTICIN ' (No septic 5r•SrPm permttud it pUL'11C Sewer is <br />available within 200 taut I <br />Installation will serve- Residence -,F— Commercial _ Other <br />Number of Irving units: --I— NumDer of drooms ____3?.- _— <br />Character of soil to a depth of 3 feeuWater table depth _ <br />SEPTIC TANK Type/Mfg _-__ Capacity_ D17- No. Compartments <br />PKG. TREATMENT PLT. ❑ IC 7 It Method of DrSal <br />Distanca to nearest. Well J Foundation Property Line <br />LEACHING LINE No. 8 Length of lines J 7 F _ IrX Tuial length/size <br />11 i <br />FILTER BED LI Distance to nearest: Well TO Foundation _/Q Property Line <br />SEEPAGE PITS I Depth —Size r Size r X I� Numbor <br />n� a1 <br />SUMPS UiZ5lance to nearest: Well �_ Fourtttaton �_ Property Line .. - <br />DISPOSAL PONDS Yl <br />I hereby certify that I have prepared tfas application and that the walk will Ix done in accordance with San Joaquin county ordinances, slate laws, and <br />rites and rogulatiuns of the San Joatpnn I ocal Health D:e:trWl. <br />Home owner or licensed agent's signalure certifies the toflowing_ "I certify that in tine performance of the work for wh`ch this permit is issued, I shall not <br />,_-S mpioy any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or Sub contracting wrtahlre <br />'t:enifies the following; "I certify that in the performance of the work for which this permit is issued, I shall employ persons sutjact to workman's compens3- <br />tiun Laws o! California." :. - <br />The appicant must call a required inspections. Complete drawing on rrevversu side. <br />Signed X I I 1 n g: L -- - — Date: <br />FOR DEPARTMENT USE ONLY <br />Application Accepted b --v Date _ Arne_ _ <br />iii l Final Inspection b "r Late <br />it Grout Hsps tion by _ t+ F�� Pe Y <br />Addrtofftment3: _ r --• r - — — <br />L Stk 466-6761 O Lodi 369-3621 ❑ Manteca 823-7104 F: Tr&Cy 835-6385 <br />Applicant - Return all copies to; Environmental Health Permit!Services 1601 E. Hazelton Ave-, P.O. Box 2009, SM., CA 95201 <br />. EH 13241AEV.+ <br />Eli 14 20 <br />FEEAMOl1NT <br />INFO <br />RUE <br />AMOUNT REMITTED CK <br />C ASH <br />RECEIVED 8Y DATE PERMIT No. <br />