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APPLlCATl0111,,. R PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL_T ON AVE., STOCKTON, CA <br /> Telephone QW) 486-6781' <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED­` <br /> j' <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described 1 <br /> '.Vit'^ <br /> made H compliance with San Joaquin;County Ordinance fVo.549 for or No;1862 for well/pump-and the Rules and-Reguiations of the San Joa uin <br /> Local Health District. This application is <br /> Job Address 7,5 q. <br /> r <br /> City <br /> _ ktstYSize <br /> 5' <br /> 4 PM <br /> Owner's Name ►1? 1 �. <br /> t, G` Address <br /> Phoria <br /> Contractor's Name "C�CIC.� „� <br /> --�_ License No. �C /fes ' <br /> TYPE OF WELL/PUMP: <br /> NEW WELL ❑ �0 ~� 'Phone 7C� <br /> r WELL REPLACEMENT Li DESTRUCTION— 0 <br /> PUMP INSTALLATION- ❑ _ _ <br /> DISTANCE TO-NEARESTf'.SEPTIC TANK r " SYSTEM REPAIR OTHER Cl O <br /> —•—,�__ SEWER LINES ; <br /> f DISPOSAL FLO. PROP. LINE PITS/SUMPS <br /> _ FOUNDATION _ � AAGRICULTURE WELL. <br /> INTENDED USE _ OTHER WELL. <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom <br /> ❑ Manteca Dia, of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy T Dia. of Weil Casing, <br /> EJ Public ❑ Other Type of Casing <br /> ❑ Delta Depth of Grout Seal Specifications <br /> CJIrrigation ---Approx. Depth 17 Eastern Type of Grout <br /> Repair Work Done /) Surface Seal Installed by. <br /> i Type Pump _ H.P, State Work Done <br /> Well Destruction E2 .-E.Well Diameter Sealing Material (top 50'; _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK! NEtN'INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is r. 9 <br /> .n i <br /> Installation will serve: Aesidence_ Commercial— Other available within 200 feet.). <br /> Number of living units::' ' Number of bedrooms —~ ~— <br /> Character of soil to a depth of 3-feet: _ <br /> SEPTIC TANK <br /> ;1 Type/Mfg <br /> kyr Water table depth <br /> .. _ <br /> PKG. TREATMENT PLT. ID ' No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> �- Property tine <br /> LEACHING LINE f❑ No. & Length of Ii Total length/size <br /> FILTER BED ❑ Distance to rest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ pth Size Number l <br /> SUMPS Distance to nearest: Well Foundation Pro -, 9- + <br /> DISPOSAL PONDS ❑_ Party Line <br /> r <br /> 1 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 performbnce 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 applic call for all require spectf s. Co tete drawing.on-reve sfde. 1 <br /> Signed _ S <br /> . '�' ,Ttle• ' Date• <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 t Date �� d <br /> _ Area f <br /> Pit or Grout Inspection by Date Final Inspection by _ Date <br /> Y �. . <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEEgMOUNT DUE AMOUNT REMITTED CK# RECEIVED[BY DATE_ PERMIT•`ND. <br /> INFO <br /> ' CASH <br /> ao <br /> EH 13-24IREV.10/831 (/`]}�Q <br /> EH 14-28 <br />