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• C) APPLICATION FOR PERMIT <br /> /� SAN JOAQ604 LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> 'I c� <br /> Telephone (209) 466-6781 PERMIT N0. S.(3'�( S <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED DATE ISSUED L"I'Sk3 <br /> { (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a <br /> described. This application is made in compliance with San Joaquin County pOrdinanccermit toe No. 55449tfor dsewagesoriNo. 18work62f herein <br /> 4 and the Rules and Regulations of the San Joaquin Local Health District, 62 for well/pump <br /> Job Address <br /> ' Sura9iviorr rya, �j <br /> Owner's Name L(, Address Q <br /> Contractor's Name �}L(f -� Mb. Phone <br /> License No. Phone <br /> TYPE OF WE WORK: NEW WELL ❑ WELL REPLACEMENT <br /> ❑ DESTRUCTION❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES " <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED SE TYPE OF WELL PROBLEM AREA <br /> ❑ Industrial CONSTRUCTION SPECIFICATIONS <br /> ❑Open Bottom ❑Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑Grivel Pack Tr <br /> ❑ Public ❑ ac y Dia. of Well Casing <br /> [j OtherDelta <br /> + Li Irrigation ❑ Type of Casing <br /> i Approx. F1 Eastern <br /> ❑Cathodic Protection Depth Specifications <br /> ❑Geophysical Depth of Grout Seal <br /> (J(Other Type of Grout <br /> Repair Work Done ❑ Type of PumpH P Surface Seal Installed by <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION <br /> (No septic tank or seepage pit permitted if public sewer is t <br /> Installation will serve: R sidence tJ Commercial _ Other available within 200 feet.) <br /> Number of living units: ---L______ Number of bedrooms Lot size <br /> i <br /> Character of soil to ah of 3 feet: { <br /> Water table depth <br /> SEPTIC TANK Type/Mfg Capacity <br /> y No. Compartments <br /> PKG. TREATMENT PLT. ❑ Type/Mfg Ca acit <br /> SENAGE SYSTEM p y Method of-Disposal <br /> F, D&STRUCTION [] Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE _ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line F <br /> }-^ SEEPAGE PITS Depth ` zee _ 3 �� Number <br /> E ) SUMPS - Distance to neare W 1 9 , ou <br /> (� Foundation _,rte___ Property Line <br /> DISPOSAL PONDS <br /> r <br /> I hereby certify that I have prepared t s application and that the work will be done in-accordance with n Joaquin countJIAOy <br /> J ordinances, state laws, and rules and r ulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signatu certifies ollowing: "I certify that in the performance of he work for which this <br /> permit is issued, I shall not employ an rs <br /> Contractor's hirsuch manner as to become subject to workman!s compensation laws of California." <br /> ing or sub-contracting signature certifies the following: •I certify that in the performance of the work for which <br /> this permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> The applicant s call for requir i pections. Complete drawing ow�n//reverse side. <br /> Signed X itle: .��► <br /> Date: 9-" <br /> FOR DF,PARTME <br /> � Application Accepted b ea �f Stk 466-b781 <br /> Additional Commen <br /> Lodi 369-3621 <br /> Pit or Grout Ins on Date ❑ nteca 823-7104 <br /> 1 <br /> Final inspection by Date �i ❑ Tracy 835-6385 <br /> l Applicant - Return all copies to:. Envir mental Health Permit/Services 16011E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> { FEE BASE AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> INFO DATE PERMIT NO. <br /> F 5 ND <br /> F" ;EH-13-24 <REV. 10182 a`, ,,. r• ':� ^7x - 10/82'500 <br />