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APPLICATION FOR PERMIT 111 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 416011E.•HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone <br /> PERMIT EXPIRES`VYEAR FROM DATE ISSUED <br /> -~ .'(Complete in Triplicate? <br /> { Application is hereby made to the San Joaquin bca Health District for a per'mt to construct and7or instatl'fhe work]+erein-described sThis-application is <br /> made incompliance with San 3oequin my Ordinance No. 549_for-sewage orNo. 1862 for wellipump and the Rules and Regulations of the an Joaquin <br /> Local Health District, <br /> \�' PM <br /> Job Address City Lot Size <br /> l Owner's Name <br /> .Address Sty Z) Phon <br /> 1 r- -$7r <br /> Contract C Address - License No Phon a <br /> TYPE OF ELL/PUMP:_ .n� NEW WELLS® WELL PLACEMENT,-0 <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION C� '' SYST�E�MREP.�A-IR ❑ OTHER ❑ <br /> L DISTANCE TO NEAREST: SEPTIC TANK Jr�D �SEWFR LINES /s��^_��+�. DISPOSAL FLD6" (PROP" LINE . <br /> FOUNDATION --�AGRICULTUR WELt.Q_+ OTHER WELL Q0�1_ ITSISUMPS r <br /> t •. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom AC] Manteca Dia. of Weli Excavation Dia. of Well Casing <br /> 15 E 24L e+ Specifications <br /> IK Domestic/Private [-]-Gravel Pack ❑ Tracy Type of Casing <br /> � Public R Othei-Mon"' �A Delta Depth of Grout Seal Type of Grout Cf <br /> i / 1 _ <br /> f^I Irrigation 1$�"Approx. Dep l I Eastern Surface Seal Installed by �1 aflW11_e- - <br /> Repair Work Done ❑ Type of Pump H.P, $tate Work Done <br /> l Well Destruction El Well Diameter Sealing Material ]top 501 <br /> ! Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: - NEW INSTALLATION (:I #REPAIRIADDITION (.1 DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.] <br /> 1 <br /> Installation will serve: Residence Commercial_ Other 15_� <br /> l Number of living units: Number of bedrooms ;r <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK L3TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT'PLT. ❑ � ` .. :Method ofDisposal <br /> Distance'to nearest. Well Foundation Property LinZ� T .� <br /> i n � <br /> LEACHING LINE ❑ No. &rLength of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property MAY1_- <br /> Ii SEEPAGE PITS f i Depth` Size Number ENyli? I" <br /> [ t <br /> SUMPS ❑ Distance to nearest: Well Foundation Property � NEAL�W <br /> DISPOSAL PONDS ❑ l-CFS <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 and regulations of the San Joaquin Local Health District. <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 Contractor's hiring or sub-contracting signature <br /> } certifies the following: "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 /> tion laws of California." ' <br /> The applica ust all f%equi� in clions. Complete drawing o averse side. <br /> Signed X Title: © e: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate Area <br /> Pit or Grout Inspection bDate Final Inspection by Dat <br /> owt <br /> t ' <br /> Additional Comments: Y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 r ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I. <br /> FEE AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED-BY'INFO DATE PERMrr'NO. <br /> ( /��/j <br /> i + EK 13-24 tREV.1/"5) � 1 J � / l Vila <br /> / <br /> EH 1426 13�IIJJ <br /> a <br />