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?' > APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> it Telephone (209) 466-6781 <br /> PERMIT EXPIRES-1 YEAR FROM DATE ISSUED w <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County Ordinance No.549 f serge or No. 1662 fo�ll/pu�the R}les and Regulations of the San Joaquin <br /> Local Health District. �q P A,�y '? `°d,1r!`, <br /> City Lot Size PM <br /> Job Address <br /> r <br /> Phone <br /> `3 i <br /> Owner's Name Address r r1 <br /> Contract <br /> �Ada �/ License N 3���Phon <br /> NEW WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: M � SYSTEM REPAIR ❑ -OTHER ❑ <br /> PUMP INSTALLATION- <br /> SEWER LINES ��- DISPOSAL FLD. - PROP. UNE <br />'i DISTANCE TO NEAREST: SEPTIC TANK �. OTHER WELL PITS/SUMPS <br /> FOUNDATION .AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing. <br /> i en Bottom ❑ Manteca Dia. of Well Excavation <br /> - ❑-Industrial r Type of Casing 'e�6GL Specifications <br /> �mestic/Private ❑ Gravel Pack ❑ Tracy i4® r <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> fl Public Ll Other QSK �yr�pu� - <br /> —.Approx. Depth I I Eastern Surface Seal Installed by�f •. <br /> 1)- at on /L H.P. State Work Done — <br /> Repair Work Done ❑ Type of Pump <br /> F.l <br />� Sealing Material (top 50'1 <br /> Well Destruction ~❑ Well Diameter Filler Material (Below 50') <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 1 DESTRUCTION I i alvailablelwi within 200 feet.c system t if,public sewer is <br /> � a <br /> Installation will'serve- Residence L Commercial_ Other e?' <br /> A <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ❑ Type/Mfg Capacity No. Compartments <br /> Mf <br /> SEPTIC TANK Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property line <br /> Distance tonearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length' of lines Pro ert Line <br /> FILTER BED ❑ Distanca to nearest: Well Foundation P Y r <br /> Er <br /> k SEEPAGE PITS 'd Cl DepthSize Number, <br /> SUMPS 0 Distance to nearest: Well <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cdunty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di1trict. <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, I signature <br /> she not <br /> s of <br /> ornia."Contractor's <br /> certifies any the person <br /> i in sulc�manner <br /> as to n the perm mabject of the work n'swhichthis permit nsation v s issued,fI shall employ perrsonslsubject t workmanring or `scompensa- <br /> rg: <br /> tion laws of California." <br /> The applica m t call for all r qulred i spections. Complete drawing on�@ve s <br /> �. Title: L/- o2 Date: <br /> Signed X <br /> l FOR DEPARTMENT USE ONLY <br /> f Date " " 'Area 0 <br /> Application Accepted by - <br /> ,,,�..�. <br /> � ��I� Date - Final _T. . . ..__ _:• <br /> � Pit or Grout Inspection by Inspection by. ��- - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ElMenteca 623-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> tcK RECEIVED BY DATE PERMITNO. <br /> OUNTR'EN 13-24(REV.1/H 51 � U� Jo 4 U <br /> EH 14-26 <br />