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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t and/or install the herein describe . This application is <br /> AppliHealth District for a <br /> nte with Sano)aquin CounLocaluin permit construe <br /> rk <br /> ty Ord nance No.549 for sewage or No. 1862 for <br /> made wellipump and the R o s and fl gulations of he San Joaquin <br /> made Inn compliance <br /> Local Health District: : I <br /> P M { <br /> Lot Size <br /> Cit <br /> Job Address <br /> ��lddress` ° Phone <br /> Owner's Name <br /> .e=- t:!r--�w-.-�w`'.+•-Y..rn.T 4•b►....�-.w..i..=�...JyL.,+�.�+'•�t-/�'y�,.�-'-'_`s�f+ <br /> Contractor <br /> Li K ■/4/JfSO� Address _�3 �d -� `��1� -License No. ` Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> —DISTANCE-TO NEAREST:.SEPTIC_TANK- _S EWER:LLNES__ _ DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> [IIndustrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing f, r <br /> Specifications <br /> [1 Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> A ro Depth I 1 Eastern Surface Seat Installed by <br /> t I Irrigation --- PP I� P . <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Sealing Material Ito 50'1 <br /> Well Destruction ❑ Well Diameter 9 P <br /> �1 Filler Material (Below 50'1 1 <br /> Depth -' <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION [.1 REPAIRIADDITION lL`LL.DE'STRUCTION € I (No septic system permitted it public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> r�- <br /> Number`af living units: Number of bedrooms <br /> f Character of-soil to a depth of 3 feet:•- Water table depth <br /> SEPTIC TANK it <br /> k1 i❑., Type/Mfg j Capacity No. Compartments <br /> + ` Method of Disposal <br />' PKG. TREATMENT PLT. ❑ 14 g <br /> Distance to nearest: Well Fo ndatlon Property Line <br /> LEACHING LINE 04�i b. & Length of lines Total length/size S <br /> o Property <br /> Line <br /> Distance to nearest: Well Foundation <br /> FILTER,BED ❑ <br /> ` - 0 <br /> I SEEPAGE'PIT,S; r y ,Pth. Size Number <br /> 60 <br /> SUMPS L] Distance to nearest: Well __ Foundation ` Property Line <br /> I DISPOSAL PONDS <br /> I 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 acid regulations of the San°Joaquin Local.Health District. _ -.r._r:.,- ,", •�„. <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 California." Contractors hiring or subcontracting signature <br /> cartifl a following: "1 certify at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> rf tion laws o ' rnia." i" <br /> I The applicant ust c _ a I quire in Ion Com d awing 6h Y6yelCse si + ^� <br /> f Signe e: .� Date: <br /> # FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout inspection Date Final Inspection by Date <br /> i# w �� ©,— <br /> Additional Comments: „y <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 El Tracy 835-6385 --/'7..aka Z1 , ",,.,r mL <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, tk., CA 95201 0 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIYNO. <br /> F INFO <br /> S +.EH 13-24 IREV,119 of <br /> r[� EH 14-26 <br /> i - <br />