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r <br />APPLICATION.FOR PERMIT r,=-- <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZETON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />q(Complete in Triplicate}. Lo/ <br />Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application ismadeincompliancewithSanJoaquinCountyOrdinanceNor549forsewageorNo. 1862 for well/pump and the Rules and Regulations of the San JoaquinLocalHealthDistrict. <br />Job Address city Q G Lot Size PM <br />Owner's Name 1 Address Phone <br />Contractor Address-_-_ „ C License No ft Phone <br />I& <br />IT8 <br />TYPE W.WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION <br />PUMP INSTALLATION El SYSTEM REPAIR C1 OTHER C1 11 <br />t <br />DISTANCE TO NEARES : TANK SEWER LINES—;" ' DISPOSAL FLD. PROP. LINE <br />FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS _ <br />INTENDED-USE--"—TYPE-OF'WEL: —PROBLEMAREA UC'rONNSPECIFjCATIONS <br />Industrial Open Bottom Manteca Dia. of Well Exc ti Dia. <br />f <br />of Zell Casing Domestic/Private LJ Gravel Pack LJ Type of Casing S pecifi tionsPublicOtherDeltaDepthofGroutSealr <br />rout r <br />Irrigation Approx. Depth Eastern Surface Seal Installed by <br />Repair Work Done Type of PumpH.P. State Work Done <br />Well Destruction Well Diameter f- •---Sealing Material (top 50'1 tl . <br />DepthFiller Material (Below 50') <br />TYPEOF SEPTIC WORK: NEW iNSTALLATION< -REPAIR7ADDITION DESTRUCTION ,(No septic system permitted if public sewer is <br />ter,-available within 200 feet.IInstallationwillserve: Residence AL Cotmnercial— Other <br />Number of living units:—I— Number,of bedrooms F, <br />r <br />Character of soil to a depth of 3 feet( <br />t E <br />Water table depth r <br />SEPTIC TANK F1Type/Mfgf _p <br />w . - pacty No. Compartmentsrw..... PKG. TREATMENT PLT. tr <br />u,1., A G <br />Method of Disposal <br />k• Distance to"nearest: Well Founifation G `. `Property Line <br />LEACHING LINE O No s&-d6ngth of liries,Tota! I9'ngth/size F <br />FILTER BED Distance to nearest WeilYVI2—9 Foundation Property Line <br />AIA Z- <br />SEEPAGE PITS De th-Y_'V 1,. ' i"p ! <br />F <br />Size Number <br />SUMPS I - Distance to nearest: Well Foundation Property LineDISPOSALPONDS f 1 1 <br />I hereby certify that I,have prepared;his application and that the work will be done in accordarice with San Joaquin county"ordinances, state laws, andrulesandregulationsjof,the Sark Joaquin.taocai Health District. <br />employHome <br />owner or licensed a`gent's'`signature certif;es the following: "I certify that in the performance of the work for which this permit is issued, I shall notypersonin.such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signaturecertifiesthefollowing:"I certify tha6the performance of the work for which this permit is issued, Ihall totionlawsofCalifornia?" f' em P Y persons subje{ct to workman's compensa- <br />The applicant must call-f all r guired inspections.Complete drawing on reverse side. F <br />r t <br />Signed X <br />s <br />Title:'Date:I Date:, <br />t <br />FOR DE ARTMENT USE ONLY <br />4 Application Accepted by <br />i t•t Date 0 Area <br />Pit or Grout Inspectit by r 1 Date Final Inspection 6y ! Dateg <br />Additional Comments: V 4, <br />11 Stk 466-6781 Lodi X693621 kr Manteca 823-7104 13 Tracy 835-6385Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O 1 Box 2009, Stk., CA 95201, I <br />9* <br />s' <br />y y <br />FEE AMOUNT-DUE•.R. _-A NT REMITTED»K" K RECEIVED-BY'" ""'`DATE"' 6—INFO"`"CASH._r <br />EH 13-24(REV,17 a 51 <br />EH 1428• r