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w[ 'rp6 <br /> APPLICATION FOR PERMIT 73 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 6 0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> AppJoaquin Local Health District for a <br /> made intion is hereby compliance with Sanade othe Joaquin nCounty ordinance No.549 for sewagermit to orNo. 1862 forcwell/d/or install the work pump and the Rules and herein descnbes, <br /> Local Health District. This application is <br /> r Regulations of the San Joaquin <br /> Job Address ✓ 317a <br /> City of Size Z� C5 PM <br /> Owner's Name C �isLKP?S a�j � <br /> Address Y O 7,1'5? <br /> ' Phone <br /> Contractor �o g00)- * Address_ •a' iVic 3 Sf�r <br /> TYPE OF WELL/PUMP: License No.E' f/ Phone Lf6�Z�v�6 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> / PUMP INSTALLATION El SYSTEM REPAIR Q <br /> ! D15T/NCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> �ER LINES DISPOSAL FLO, <br /> FOUNDATIONAGRICULTURE WELL _ PROP, LINE <br /> J INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PR—OB�i AREA 1.7 <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom IVlan'Ll face, <br /> Domestic/private ❑ Gravel Pack x.� • Dia. of Well Excavation Dia. of Well Casing <br /> Tracy T <br /> Public `.��•�g ❑ Other ` Type of Casing Dia. <br /> ❑ Delta Depth of Grout Seal <br /> '❑ircibation ' _- --�iType of Grout <br /> �Approxepth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Q TWO <br /> H.P State Work Done <br /> Well Destruction Q_ 6}Veil Diameter Sealing Material (top 5o') <br /> Depth Filter Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATI ❑�' REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> i Installation will serve: Residence available within 200 feet.) <br /> / Commerd�a Other <br /> Nuinber�f living units: �s Number of bedr' 6 <br /> 7 Character of soil to a depth of 3 feet: <br /> SEPTIC TANK C7 Type/Mfg Water table depth <br /> r r Capacity_�� <br /> PKG. TREATMENT PLT, ❑ f No. Compartments <br /> � Esi�: � Method of Disposal <br /> Distance to neaWell Foundation <br /> Property Line <br /> LEACHING LINE iONo. & Length of Ines 0 F� <br /> FILTER BED Total lenithe <br /> LJ Distance to.nearest: Well Q0 t Foundation l00'� <br /> py Line <br /> SEEPAGE PITS <br /> Depth �' �� Size �'� /aYC NumberRU1.MPS /` El Distance,to-Ineprest. Well Foundation l pGi DISPOSAL PONDS ❑ ;�- PLine 000$ <br /> I hereby certify that I have prepared this ap'lication and that the work will be done in accordance with San Joaquin county ordinances, state la-w. and <br /> �\ rules and regulations of the San Joaquin cal Health District. <br /> Tome owner or licensed agent's signatureertifies the following: -1 certify that in the performance of the work for which this permit is issued, I shall not <br /> e?nploy any person in such manner as to *oma subject to workman's com <br /> certifies the followin - pensation laws of-California."Contractors hiring or sub cor+'.actng signature <br /> ig: "I ceRify that in(�,perfgrmance ale work for v{rhich this rmit is issued, I shall employ tion Taws of California." � '�+ ( � � p y persons subject to wcukman's compensa- <br /> The applicant must'c for all re4uked i ctfons_'Complete drawing n <br /> reverse Lide. , <br /> { <br /> Signed <br /> Title: Date:.''` ?-�`6 <br /> ~ <br /> FOR DEPA<"TMENT USE ONLY <br /> Application Accepteby --�--y- <br /> Date !�-2zOf. Area <br /> Pit r Grout Inspection by Date <br /> Lo Final Inspection by Date <br /> Additional Comments: R_,T" 1fChi <br /> ❑ Stk .466-6781`---•°•E] Lodi '369=3621 0-Manteca"823-7104 " ❑Tracy 83545Mi <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,CA 95201 '� w <br /> FEE i <br /> INFO AMOUNT DUE AM= CASH <br /> CK RECEIVED BY <br /> DATE PERMiT'NO. <br /> + EH 1324(REV,vast �,� <br /> EH 1b26 �'� b o / 11r 5s6�� <br />