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APPLICATION FOR :11411 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6791 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Appska ion Is hereby made to the San Joaquin Local Health District to-a pgmmit to construct end/or Install the work hei described.This application:5 <br /> j meds N compliance with San Jpaguin County Ordinance No.549 for semi or No. 1862 far well/pump and the Rules and Regulations of this San Josquln, <br /> Local Health District. <br /> I <br /> L, <br /> Job seeress City 1001 -of si" PM <br /> Owners Name <br /> J�/ aAddress �T� Phone .. <br /> /torn lCoovz2 ;goo �t�?2zo�o/ii �6r76iis <br /> Contractor Address `-'✓' License No. <br /> Phan <br /> TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT G DESTRUCTION C � . <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER LT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.-_ PROP.LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PRS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS o- <br /> ❑Industrial O Open Bottom G Manteca Dia.of Well Eacavadon Dia.o/Well Casing <br /> E <br /> i G Doneshc/Private ❑Grew)Peck ❑Tracy Type of Casing_ Specifications <br /> ❑ Public O Other ❑ Cars Depth of Grout Seal Type of Grout <br /> O Irrigation _Approx. Depth G Eastern Surface Seal Installed by '. <br /> !. Repair Work Dons ❑ Type of Pump H.P.- -Z <br /> State Work Done" '` <br /> Well Destvc'on G WNI Diameter Sealing Material Itop 50'1 la'' <br /> Depth Filler Material(Below 501 ri <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITIONVOESTRUCTION ❑ (No septic rival permitted 4 public sewer Is <br /> available within 200 feat.) <br /> Instali.sell sena: Residence_ Commercial_ Other <br /> Number of Fving units:_ Number of bedrooms - ) 11, <br /> Character of sod to a depth of 3 lead: Water table depth Q! <br /> SEPTIC TANX G Type/Mfg Capacity_ No. Comparmems <br /> 7 <br /> f Pi TREATMENT PLT.O Method of Disposal i <br /> Distance to restart: Well Foundation_ Property Line K. <br /> r t <br /> t �0 Total length/nze_ �- <br /> LEACHING LINE �No. 8 Lergth of lines <br /> FILTER BED O Distance to nsnest We:1 f�. Foundation Property Line <br /> 9 <br /> SEEPAGE PITS C Depth Size _ Number <br /> ,. SUMPS G Distance to nearest: Wel Foundation Property Line <br /> DISPOSAL PONDS C <br /> I hereby certify that I hes prepared this application and that Yne work will be done In accordance with San Joaquin county ordinances,nate(am,and <br /> rules and regulations of the San Joaquin Local Health Call". <br /> Hone owner,or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Is blued,I null not <br /> employ any person in such mender as to become subtri to workman's compensation laws of California."Contractors hiring or subcontracting Ognstute <br /> "tithes the fo/owir i 1,1 certify that in the perlormanns of the work for which this permit is issued,I shall employ parsons subject to workman's Conti si <br /> Z <br /> fayre of( i g i 1. <br /> The applicant nun Ull ropuir in Complete drawing on reverse side. <br /> signed / ��sp/ec/i6ys! /Gy}�.rff/,//C Data: <br /> FOR DEPARTMENT USE ONLY <br /> rr, r <br /> Application Accepted W1..----f-T+-1-� 1 ------- Date N_ !�" S— Area <br /> Pit or Grout Inspection by f`r,�,f5 Date Final Inspection by � t_ 14 1 6, 0, — Data <br /> Addrioral Comments: <br /> v SM 4668781 G Lodi 7643621 antero 823-7101 C Tracy 8766-785 <br /> Applbaet- Return an copies,to: Erroimnmenuf as Permit/Services 1601 E. Hazelton Ave., P.O. Be.201 Sik., CA 95201 <br /> DEE AMOUNT DUE AMOUNT REMITTED CASH RECENED BY DATE PERMIT IN10. <br /> (Nf0 <br /> XLLID <br />