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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 /1✓a „p <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �` I <br /> f (Complete in Triplicate) r/ <br /> I Application is hereby made to the Sen Joaquin Local Health District forathe work V <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 19tr'2 forcwellipump and the Rules and Regulations the San )ls <br /> Local Health District. <br /> Job Address City 1° Lot size PM <br /> Owners Name -� ��LN Address <br /> Vr Phone <br /> 231? 77,19 <br /> f' <br /> Contractor Address License No. Phone <br /> I TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTDESTRUCTION C] <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKIIyER LINES _ ' <br /> q� DISPOSAL FLD. � PRpP. LINE AXf <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL ��- PITS/SUMPS 1-45Yr Q� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Y <br /> Cl Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation <br /> -- /J00— <br /> Dia. a1 Well lasing <br /> ' Domestic/Private Gravel Pack 0 Tracy <br /> Type of Casing—IL Specifications &e? � <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �� Type of Grout c- <br /> ❑ Irrigation --.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> r Repair Work Done Type of Pump SciA H.P. I _ — State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 51111 <br /> ---- -.`}'L Depth � �Filler Material 16elow 54'} ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial— ether available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> s„ Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG-TREATMENT PLT.❑ { <br /> r Method of Disposal <br /> Distance to nearest: Well_ Foundation Property Line _ <br /> E " <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> ! FILTER BED ❑ Distance to nearest:, s Well Foundation Property Line <br /> k k" <br /> SEEPAGE PITS EI Depth Size Number <br /> SUMPS © Distance to dearest: -Well Foundation Property Line <br /> !4 DISPOSAL PONDS ❑ <br /> i I hereby certify that I have prepared this applicat�n arid'iliat 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 toistrict- <br /> T 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 as4o become subject til workman's compensation lawn 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 /> r The applicant must c fo 91 quired ing-actions.Cernplata drawing on red%me sie. <br /> 7t Signed :Title: - kl _. .l� <br /> E Date: <br /> Oft DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Dab�y�* <br /> Area <br /> ' Pit or Grout Inspection by Date 3-l Z incl inspection <br /> Date <br /> Additional Comments: <br /> 0 Stk 48&6781 ❑ Lodi 369-3621 ❑ Manteca 8x3.7104 ❑Tracy 835 <br /> -6385 <br /> Applicant• Return all copies to: Environmental Health Permit/Senricas 1801 E. Hazakon Ave., P.O. Box 2009,Stk., CA 95201 <br /> E <br /> FEE AMOUNT DUE =CCA <br /> RECEIVED BY DATE <br /> INFDSH PERMIT'NO. <br /> +Eti 53.74(REV.1/p 5) <br /> EHt47B. �Se 'tS 6— I7p <br /> F <br />