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APPLICATION FOR PERMIT <br /> SAN JOAO•UIN LOCAL. HEALTH DISTRICT l <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED_ ' <br /> I1 (Complete in Triplicate) application is <br /> Iand the Rules and Regulations of the San Joaquin <br /> Application is hereby made to <br /> the San Joaquin Local Health D•+strict f ewe pg o 1�0 1862 for welly stall the work herein described:This <br /> made in compliance with San Joaquin County Ordinance No.549 or s <br /> Local Health District. a. PM <br /> Sie <br /> City Lotz <br /> i <br /> Job Addressf.t Phone <br /> Address .- <br /> __ <br /> Owner's Name I A 6 Phone <br /> �O .I License No. DESTRUCTION ❑ <br /> Contractor's Name NEW WELL ❑ WELL REPLACEMENT ❑ OTHER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> AL <br /> PUMP INSTLATION 11DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES � PITSISUMPS � / <br /> AGRICULTURE WELL OTHER WELLS O <br /> _1 <br /> FOUNDATION <br /> EFROBL`Ep CONSTRUCTION SPECIFICATIONS Dia of Weil Casing <br /> INTENDED USE TYPE OF WELL Dia. of Well Excavation <br /> ❑ open Bottom ❑ Manteca Specifications .` <br /> El Industrial ❑ Tracy Type of Casing Type of Grout <br /> f ❑ Domestic/Private ❑ Gravel Pack �-. Depth of Grout Seal <br /> El Other .11 ❑ Delta <br /> [11 Public �pprox. Depth 171-Eastern Surface Seal Installed by 2 <br /> I ❑ irrigation , State Work Done <br /> H P <br /> Repair Work Done ❑ Type of Pump r— Sealing Material (top 50`} <br /> Well Destruction ❑ Well Diameter _ Filler MateriaF(Below 50'1 <br /> Depth <br /> REPAIRIADDITION ❑ DESTRUCTION ❑ availableNo lwith net00 feetil-a,1f public sewer is }, <br /> TY <br /> OF SEPTIC WORK: NEW INSTALLATION ` <br /> "__ Commercial Other a <br /> Installation will serve: Residence C ' <br /> Number of living units: Number of bedrooms i_ `�' Y Water table depth <br /> r city- No. Compartments f <br /> Character of soil to a depth of 3 feet: ��, <br /> SEPTIC TANK ❑ Type/Mfg , Method of Dis�°sal <br /> pe <br /> PKG. TREATMENT PLT. 71 -�Foundation Pr°party Line <br /> Distance to nearest: (Well -— _ U <br /> Q To Ilength/size <br /> LEACHING LINE <br /> X No. &Length of lines Property Line ` <br /> - �s�--�-- <br /> FILTER HED ❑ DistanFoundation ce to nearest: WeA <br /> Number i i <br /> ❑ Depth, Size Property Line—� je ' <br /> SEEPAGE PITS Foundation <br /> SUMPS <br /> ❑ Dist_ance to nearest: Well �t <br /> 11, <br /> DISPOSAL PONDS ❑ <br /> } eb 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 /> her Y <br /> rules and regulations of the San Joaquin Local Health District-following: <br /> rkman's compensation Paws of California." Contractors hiri6b crt to workman'scompensa- <br /> Home owner or licensed agent's signature cert�g sub ecto wo I certify that in the performance of the work for which}this permit is.issued. I slignature <br /> hall not <br /> employ any person in such manner as to beco I <br /> certifies the following-."I certify that in the performance of the work for which this permit is issued,I shall employ persons s 1 <br /> tion laws of California-" <br /> 'The applicant must call for all require spections. Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY � ? <br /> Date — Area <br /> ! Application Accepted by , Date <br /> Date Final Inspection by <br /> Pit or Grout Inspection by i <br /> tAdditional Comments: l <br /> ante <br /> ❑ Stk 46CMI ca 823-7104 ❑ Tracy, 835-6385 5til CA 95201 <br /> ❑ Lodi ;3693621 <br /> nvironmental Health Permit/Services 160 Hazelton Ave., P.O. Bax 2009 <br /> Applicant- Return all copies to: E <br /> , .,� <br /> IGCK RECEIVED BY DATE PERMIT`NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH 3' <br /> j INFO <br /> + EH 13.24(11110/83) <br />