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I01111- <br /> i <br /> APPLICATION FOR PERMIT <br />` SAN JOAQUIN LOCAL iHEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Lo. 17 <br /> PERMIT EXPIRES•l YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) C i { T <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> wage or No. 1862 for well/pump and the Ryles and Regulations of the San.Jaaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for se <br /> Local Health District. 4'. a <br /> ° .�.p plZ City Lot Siz,0? M <br /> Job Address may{' <br /> o <br /> Owner's�Name <br /> Address � � o 'v--� Phone <br /> i �] ��77 r7 (� <br /> Contract r ddress Pal License No. O 9 Cy to Phone <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ 'WELL REPLACEMENT ❑ DESTRUCTION ❑ �yf <br /> ` PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ' <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 m <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION L3-(No septic system permitted if public sewer is l <br /> available within 200 feet.) <br /> installation will serve: Residence Commercial— Other 's <br /> Number of living units:—I— Number of a rooms 1 <br /> Character of soil to a de�pth�of 3 feet: _ r , <br /> # �\ Water table depth 5 <br /> SEPTIC TANK type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i .� \Method of Disyosal <br /> { Distance to nearest: Well Foundation --,Property Line <br /> LEACHING LINE No. & Length of lines Tay.lotal length/size 41 <br /> FILTER BED ❑ Distance to nearest: Well Foundation l _ Property Line_�_� <br /> � 1 <br /> SEEPAGE PITS i� Depth, Size r��7 Nu mbe.%- <br /> F <br /> _ } <br /> SUMPS ❑ Distance to nearest: Well .:_ Foundatio-n-LIA operty Cine s <br /> pISPOSAL PONDS ❑ jy <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 /> j 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 /> i employ any person in such manner as to become subject to workman's compensation laws of California Contractors hiring or sub contracting signature <br /> i certifies the fallowing:"I certify that in the performance of the worq,f which tho permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of California." j � <br /> j The applicant st call for equi�inspe�ctions. omplete drawing onwerse`side. <br /> f le: <br /> ' <br /> Ti <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> .p� Data 7i Area <br /> Application Accepted by eY�Z,121 <br /> # i <br /> or Grout Inspection by Dater Final Inspection b�� _ _Date. Q� <br /> _._.._In.. �. _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 11Lodi 369-3621 ❑-Manteca. 823-7104 kt 40 Tracy <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Haiejton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT"N0. <br /> INFO AMOUNT DUE AMOUNT REMITTER CASH <br /> + EH 13-24(REV.1/s 5) <br /> t EH 14-25 <br />