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} <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 16011.HAZEL T ON AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT-EXPIRES-1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. Y, <br /> Job Address • city c/ �.$ PM <br /> Owner's Name �� Ll—'Q k d�L�l[ddress one <br /> Contractor14r Q 7ise No. Z 3 7�Phone +� <br /> TYPE OF WELL/PUMP: NEW WELL 11r -WILLCREPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 <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 /> D Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal T pe of Grout <br /> ❑ Irrigation ---Approx. Depth EJ Eastern Surface Sal Installed by <br /> Repair Work Done Type of Pump H.P. ' State.Work Dane <br /> Well Destruction ❑ Wet] Diameter Sealing Material (top;501 <br /> Depth Filler Material (Below 50'i ,J <br /> TYPE OF SEPTIC*WORK NEU1r iNSTALLA '❑ El!'REPAIR/ADDITION-0 DESTRUCTION (No septic system permitted if public sewer is f <br /> a TION - "` "" = F -a•y available within.200 feet.) <br /> Installation will-serve: Residence_ Commercial_ Other i l <br /> Number of liVing units + Number of bedrooms <br /> Character of soil to a depth of.,�feet: Water table depth <br /> I a .. . <br /> SEPTIC TANK ❑ Type/Mfg Capacity "No:Compartments <br /> PKG. TREATMENT PLT. ❑ r ± _t. Method of Disposal <br /> :�R <br /> Distance`to nearest: Wef1i -:r. �, Foundation Property Line � <br /> LEACHING LINE ❑. No & Length of lines I Total length/size ' } <br /> FILTER BED = �§�7``❑- Distance to earest: Well Foundation Property Line <br /> ~ SEEPAGE PITS ❑ Depth Size x ' { Number r <br /> SUMPS L t' ❑ Distance to nearest:' ,Well:N ` ti Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I h ed this application and that the.wvrk will be done in accordance with San Joaquin county ordinances, state lawns, and <br /> rules and regulatio of the San J quin Local Health District. <br /> Home owner or ' ensed agent's sig ture certifies th ollo'wing:•''I cerfrfy.that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such manner o become su t work s compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the f lowing:"I certify th the pert rm o he rk or whi his,permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifornia." J <br /> The applica t must c ora a uired ins cti raver' e <br /> ate: <br /> Signed X # - <br /> r <br /> F DEPARTMENT USE ONLY <br /> Application Accepted b Date f1� � 1 7 Area 62-- <br /> 6�7Pit or Grout Inspection y Date Final Inspection by Dat <br /> f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Trady 835-6385 <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 y RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> +EH13-24(REV. 135) 'Y.3/ �-7 <br /> EH 1429 �� �4 6 <br />