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• APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> t andlor install the work <br /> n described.Tinis <br /> cation is <br /> madle inticompliance with Sanade to)aqu nthe SanCounty Ordinance Joaquin lNto.District549 for sewage or permit <br /> No. 1662 for cwell/pump and the Rune and IR Regulations of he San'Joaquin <br /> Local Health District. <br /> Job Address 5333 E Washincrton -- City 4tncktnn Lot Size 1 7a 97 PM <br /> Owner's Name Carl Dorrell Address t t s c f-h rr rka Tana Phone — <br /> 2,42-7 <br /> Contractor's Name Jerry Jog 12 Asaoic Ucense No. 394241 Phone — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NE ST: SEPTIC TANK SEWER L S DISPOSAL FL PROP. LINE <br /> FOUNDATION AGRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE OF WELL PROBLEM AREA CONS CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open om ❑ Manteca Dia, of Wel ccavation Diao ell Casing -- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specificatio <br /> 11 Public L1 Other ❑ Delta Depth of Grout Sea Type of Grout <br /> ❑ Irrigation --Approx. Depth Eastern Surface Seal Installed b <br /> Repair Work Done ❑ Type of Pump H.P. Sta'e Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercia Other <br /> Number of living units:_ Number of bedrooms <br /> Character of soil to a th of 3 feet: We table depth <br /> SEPTIC TANK ❑ pe/Mfg Capacity No. Co partments <br /> PKG. TREATMENT PLT. ❑ Method o isposal <br /> Distanc to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length lines Total length/size <br /> FILTER BED ❑ Distance to nears Well Foun tion Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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."Contractors 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 applicant mus call for all squired inspections. Complete drawing on reverse side. <br /> 74 <br /> S ) <br /> Title: p^pg'dent Dat" -- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> + EH 13-241REV.10183) <br /> EH 1445 <br />