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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is Miebv made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.Tike application is <br /> made in compliance with San Joaquin County Ordinance No.509 for"wage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District <br /> Job Address <br /> ��� City t__jj�:JJ— Lot Size PM <br /> Owner's Nam- 1 '��`-�' I;S% v 1,1 Ackkam Phom - <br /> Conllacta Address License No. d�Phone " <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.__ PROP. LINE . <br /> FOUNDATION AGRICULTURE WELL —_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑Open Bottom ❑Manteca Dia.of Well Excavation Dia.of Well Casing <br /> j ❑ Domestic/private ❑ Gravel Pack ❑Tracy Type of Casing Specifications <br /> F1 Public f 1 Other n Delta Depth of Grout Seal _ Type of Grout <br /> p I I Initiation —Approx. Depth I I Easton Surface Seal Installed by--- <br /> Reps. <br /> y - <br /> Repair Work Dona ❑ Type of Pump N.P. State Work Ome <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material(Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION <br /> ESTRUCTION I I Ili septic system permitted it pudic sewer is V <br /> t�- available within 200 feet.) Q'- Installation will serve: Residence _� Other <br /> Number of Wing units: . Number of bsa�drooms`� <br /> Character,It soil to a depth of 3 feet: s-t ))))1��J Water uAk depth <br /> $ SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> A( PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Wag Foundation Property Line <br /> LEACHING LINE &-ITo.8 Length of lines Total length/size A, - <br /> FILTER BED ❑ Disunce ro merest: Wall Foundation Property Line <br /> SEEPAGE PITS I%L-Depth Size umber <br /> SUMPS LI Distance to nearezr Well�� Foundation� Property Lina <br /> DISPOSAL PONDS 11 <br /> 1 hereby cenlfy that I have prepared this application and that the work will be done in accordance with San Joaquin county orainances, state laws,and <br /> rules and regularions of the San Joaquin Local Health D13vict. <br /> Home owner or licensed agent'.signature camhes the following:"I cartify 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:'Contractor's hiring or wbcontracting signature <br /> certifies tM following:-, rtgy that in tIt dormence of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> t aldor a." <br /> TM:a,,Ic:nC <br /> Cin II for all r uir ins ions. —� rowing pg raved <br /> S I iile:(//�V-✓L n/4Jr Date; <br /> FOR RTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Data Final Inspection by k1j Data <br /> Additional Comments: <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑Manteca 873.7100 ❑Tracy 835 6M <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave.. P.O. Box 2009. Stk., CA 95201 <br /> fEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERM17,Mo. <br /> I.iE / CASH <br /> . FN t1N left'.i„a. ��f vV I 1 , /' <br /> EN tea <br />