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.'., � APPLICATION FOR PERMIT <br /> SAN JOAQUIN:LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL ION AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 .', <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> This cation is <br /> Application is hereby made to the San Joaquin Local Health District fQr a permit to construct adnatall the work herein nd the Rules and Regulations of he 5an1Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 to}sewage or No. 1862 or well/pump` <br /> Local Health ( PM <br /> District. <br /> 77 <br /> I ?G64 �t L Y p a — City SC <br /> of Size <br /> Job Address � - <br /> } tf 77S <br /> L js /}y - Phone <br /> Owner's Name r�IC.� tw Address <br /> IOf <br /> -� <br /> Contractor's Name <br /> �j4,p /��' S License No. � Phone <br /> NEW WELL ❑ W7 ELL REP4ACEMENT El DESTRUCTION 11TYPE OF WELL/PUMP: I _ tri i <br />( - PUMP.INSTALLATION ElE SYSTEM REPAIR ❑ OTHER ❑ <br /> lDISPOSAL FLD. PRflP�LINE <br /> DISTANCE TO NEAREST: SEPTIC'TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _ - <br /> INTENDED USIE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> O 1ndu tai ❑ Open-Boti—om ❑ Manteca i Dia; of Well Excavation <br /> T e of Casing Specifications <br /> t ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy .yp; Type of Grout <br /> C1 Public 13 Other EDDelta Depth of Grout Seal YP q <br /> El Irrigation �ppro:.:Depth Q Eastern Surface Seal Installed by C' <br /> Repair Work Done 11Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Ma4rial-Itop 50'}). <br /> Depth Filler Material (Below 501 - ~' ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION-O` --DESTRUCTION al o septic syste200 fee'titted if public sewer is <br /> a <br /> Installation will serve: Residence Commercial Other ; r r 1 <br /> Number of living units:__� Number of bedrooms— - *- � <br /> I Water table depth <br /> Character of soil to a depth of 3 feet: <br /> I SEPTIC TANK L) Type/Mfg "Capacity No. Compartments s <br /> v t� <br /> PKG. TREATMENT PLT. El +� Method•of-Disposal r <br /> Distance to nearest: Well Foundation Property Line <br /> ` O <br /> k4 LEACHING LINE ❑ No. & Length of lines Total,length/size 1 <br /> FILTER SED ElDistance to nearest: Well Foundation ', Property Line " <br /> t ^1 <br /> tY <br /> SEEPAGE PITS ❑ Depth Size{ `"- Number <br /> SUMPS ❑ Distance to nearest: Well? A Foundation ! Property Line <br /> DISPOSAL PONDS ❑ - 1 <br /> hereby certify that I have prepared this application and that'ihe 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. 1 <br /> F Home owner or licensed agent's signature certifies the following: "llcertify that in the performance of the work for which this permit is issued, I shall not <br /> ompensation Yaws of California,"Contractors hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's c <br /> certifies the folio ing:"I certify that in the performance of the work for which this permit is'issued, I•sli�ll errlploy persons subject to workman's compensa <br /> tion laws of Ca rnia." � <br /> W. The applicant all for squired'ins pe ions. Complete drawifs <br /> i g on evee side. <br /> Signed i Title: r <br /> 401 <br /> (FOR DEPARTMENT7USE ONLY <br /> Application Accepted by P"` Date <br /> Pit-or-Grout-Inspection-by,w---•-- - —-- ��Date--------- c' <br /> —. -- final-nsper 1 <br /> Additional Comments: <br /> I � *" Trac <br /> ❑ Stk 466-6781 ❑ Lodi 3W' ❑ nteca-823-7104` y'83563-8P:.0"Hoxe 20M 0.9 <br /> ;StK CA-95201 <br /> it/S6fice -E. Haelton Av- <br /> - Applicant Retum all copies'to: Environmerrtal Health`Pert - s'l <br /> CK RECEIVED BY DATE PERMIT"NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +EH 13-24IREV"101$3) 4+ <br /> EH W26 <br />