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APPLICATION FOR PERMIT <br /> f; <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> all the work <br /> . This <br /> madeApplication <br /> in o m fiance made to the <br /> San Joaqu nncounguin Local Health District for a ty Ordnance No.549 for sewage or permit <br /> No. 1862 forcwellldpump and the Rules and IR Regulations of the Sancation is <br /> Joaquin <br /> made in compliance <br /> Local Health District. � Q� <br /> ry 5�: 2R) <br /> /z City Lot Size2- X PM <br /> � Joh Address � <br /> Address / �. —2e,�4� _ _ Phone 3 <br /> Owner's Name j _ Q. <br /> a r -- ...<m.,r•r- -s— — _ . J��� Phone! �J <br /> r +Address/2 License No. <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL 171 <br /> WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS y <br /> INTENDED+USE ' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Domestic I Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> F1 Public ❑.Orher� i r Delta <br /> Depth of Grout Seal Type of Grout <br /> i I Irrigation -..Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H p �1 <br /> Well Destruction ❑ Welk Diameter Sealing Material Ifop 50') State Work Done <br /> }J <br /> Depth <br /> Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I. REPAIR/ADDITION LI DESTRUCTION l 1 availabpe'w Thin 200 feetstem .) if public sewer is , <br /> Installation will serve: Residence� Commercial_ Other <br /> r <br /> Number of living units: Number of bedrooms ..— <br /> _ Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity_/A -- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method o�f,Di�sp�osal <br /> LJ L— '+ <br /> Distance to nearest: Wel! /&40 .Foundation�Q_� Property Line r <br /> LEACHING LINE No. & Length of lines Total length/size <br /> Property Line <br /> FILTER BED ❑ Distance to nearest: Well�— Foundation V <br /> �^ � ,'�.l l <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundations Property Line <br /> DISPOSAL PONDS ❑ 1 0 <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 /> ' 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, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring <br /> subject sub-contracting orkmansompature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons <br /> tion laws of California." i <br /> The applicant ust call for al quired i pections. Complete drawing on reverse side. <br /> I Title: <br /> Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY ! <br /> ,_ Date U Area <br /> Application Accepted by ! I _ <br /> �-- at <br /> Pit or Grout Inspectio b Date Final Inspection _ <br /> 0 b ' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 , <br /> Applicant Return all copies to: Environmental Health Permit/Services 1501 E. Hazelton 41 e., P.O. Box 2009, Stk., CA 95201 <br /> r CK x RECEIVED BY DATE PERMIT'NO. }� <br /> ' FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> EH 13-241kEV.tiKsl 4��CyC7 <br /> EH t4-2e L <br />