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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE., STOCKTON, CA ,l <br /> Telephone (209) 466-6781 RRCRIVir , <br /> .PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> n <br /> (Complete in Triplicate) AU6 <br /> application is <br /> Application is hereby made to the San Joaquin Local Health District for a pe or permit <br /> 1862 forcwe I tlpump and/or install oe work herein describe This he San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 54B for sewage yu <br /> Local Health District. l T <br /> j ti ✓ City 3 Lot Size PM <br /> Job Address r <br /> Owner's Name <br /> C=.r' Address a ow OK9,901 Phone 70 <br /> Li <br /> 2 f� <br /> Co SU Address O q License No.- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE <br /> FOUNDATION• AGRICULTURE WELL OTHER WELL — ..PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing f <br /> ❑ Industrial L) Open Bottom Ll Manteca Dia. of Well Excavation <br /> ❑ Trac Type of Casing Specifications <br /> Domestic/Private ❑ Gravel Pack Y I <br /> ❑ Public <br /> F Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.-Approx..Dep h I I Eastern Surface Seal installed by f <br /> Repair Work Done ❑ Type of Pump. � H.P. l State Work Done 6 <br /> Sealing Material (top 50') <br /> Well Destruction ❑ Well Diameter 9 (� <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i 1 DESTRUCTION t I (No septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> I Capacity No. Compartments <br /> SEPTIC TANK El Type/Mfg <br /> PKG. TREATMENT PLT. ❑ ; Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 3I �I <br /> I l <br /> LEACHING LINE 171No. & Length of lines Total length/size <br /> :l <br /> FILTER BED LJ Distance to nearest: Well Foundation Property ,ne <br /> I I Depth i Size _ Number <br /> TS <br /> -�—=.- Property <br /> SEEPAGE P1 <br /> °"r'SUMPS ff]" Distance to nearest: Weft <br /> l DISPOSAL PONDS ❑ 0 <br /> E <br /> I 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 /> I 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, !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 compensa- <br /> tion laws of California." ` <br /> The applicant st call for all require 'nspe!lbns. Complete drawing on reverse side. 3 ^^� <br /> Signed X Title: V Date: `7 <br /> FOREPARTMENT-USE O � r� <br /> i <br /> Data r Area `] <br /> Application Accepted by <br /> 9 {° ✓J��� Date <br /> Pit or Grout Inspection by Date Final Inspection by ' <br /> r� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3&21 ❑ Manteca 823-7104 ❑ Tracy 835-6385 �( 1\ <br /> I Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95241 <br /> r �1 <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO LTD <br /> rJ `j <br /> ..ell 13-24(H£V.,i H 5) �� <br /> D 7 <br /> r <br /> EH 14-26 <br />