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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 /> Applicat <br /> /or install the work <br /> n described. This <br /> cation is <br /> made in Iccompliance withdSan J aquinto the SanCounty Ordinance Nto.549 for sewage or Joaquin Local Healh District for a permit <br /> No. 1662 for cwell/dpump and the Rules and IR Regulations of he San l Joaquin <br /> Local Health District.) <br /> Job Address p <br /> �/ A-Z� ,iEZ,1?t/ eC� city l/YXc' de4AOt Size PM <br /> - <br /> D <br /> ��,(L FD�L3 X11 ,Address / �� 2/ ^s� Phone <br /> Owner's Name � <br /> Contractor <br /> v'J Address <br /> � � ��✓.CCG( License No.�r'�Phone <br /> C ' <br /> r TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION)Y SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casin <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9 <br /> t,_. Type of Casing Specifications <br /> jµomestic/Private ❑ Gravel Pack ❑ Tracy g Type of Grout_ <br /> ("1 Public 171 Other ❑ Delta Depth of Grout Seal -�. <br /> I I Irrigation —Approx. Depth.���I iI Eastern SprlAye Saal Installed by 'A,� L Z <br /> Repair Work Done ❑ Type of Pump !SVA H.P. 7 7— State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 /N Nil L€l,�,& fpi/'1'�� <br /> Depth Filler Material (Below 50'1 <br /> E A%Q2 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (Nailableo septtic Sys Shin m permitted if public sewer is <br /> Installation will serve: Residence.— Commercial_ Other C <br /> Number of living units: _ Number of bedrooms <br /> Water table depth q, <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK L] Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> t. <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> tr SEEPAGE PITS I I Depth Size Number h <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 1 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 performance of the work for which this permit is issued,I shall employ persons subject to workman's compens t- <br /> lion laws of California." <br /> The applicant ,%�/Y/oma"Y��II regmr / ctions. complete drawing on rdeyy�/J/�I /V <br /> Signed X /�/PL�w� L3Zr//! � Title: Data X37 <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �� , � Date Area <br /> t.' Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6365 <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 /> ..EHI it IRM ii xsr <br />