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13W <br /> I <br /> om <br /> APPLICATION,FOR PERMIT S- , .,.-,; - <br /> SAN JOAQUIN,LOCAL,,HEALTH DISTRICT <br /> 1601 E.�HAZELTON,AVE., STOCKTON, CA PK­lti, <br /> Telephone (IM) 466_6761' W ,' 4,ovv <br /> 10 M ,: lip <br /> PERMIT EXPIRES .I.YEAR FROM,RAT.E.ISSbtD,;, , <br /> ljuzz�,,nl.tlsnZvc-) (Complete.in Triplicate)x <br /> n'Jj' d TH 061ii is <br /> fff Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work heriin escri e s a <br /> made,in coinplianC6 with-,SanJoa4uin CoLnty�Ordinance No.,;549 for sewage or Nm.11862,for well I pump.apd,the Rules and-.Regulations of the San Joaquin <br /> Local Health Dli!3", Ii:"i IS'11'-i­,�ktl '10A 'T' <br /> J3 S 0J t <br /> 3901 '!�`9t3totkto;n 286"ACr <br /> Job Address .—LovSize PM <br /> Owner's Name Address W Phone <br /> Contractor's Name.; Clark Well371560 462-7676 <br /> License No. Phone <br /> :TYPE OF WELL/PUMP: SYSTEM REPAIR-El- <br /> NV'1It 11 [1 WELL REPLACEMENT 09 DESTRUCTION 11 <br /> PUMP INS ION OTHER 0 <br /> - <br /> DISTANCE TO NEARES... SEPTIC TANK !E�1.[3jO -SEWERDISPOSAL FLD. <br /> ,LINES PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP ECIFICATJ9,NS_ <br /> /8 <br /> I U -�J <br /> D Industrial El Open Boticim ;E] Manteca Dia. of Well-Excavation Dia. of Well Casi <br /> 6 5/8R <br /> PVC <br /> El Public bu <br /> -*1 Domestic/Private IN Gravel Pack El Tracy Type of Casing— Avi —7 -Specifications <br /> I <br /> AIL ther D.elta- Depth of.Grouts :Ty.pe of Grout.9entonite <br /> ❑ JL <br /> I —_ <br /> Irrigation pprox- -- <br /> Depth D Eastern 'Surface Seal Installed by: owner <br /> Repair Work Done e 0 Type of Pump H.P. State Work Done <br /> ' <br /> Well Destruction 11 Well Diameter Sealing Material (top 561 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C REPAIR/ADDITION E DESTRUCTION El (No septic system permitted if public sewer is <br /> . . . . .. available within.200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units:— Number of bedrooms <br /> -Character of soil to a depth of 3 feet: -Water table depth <br /> SEPTIC TANK El Type/Mfg. Capacity. No. Compartments <br /> PKG. TREATMENT PLT. I'] Method of Disposal <br /> .Distance to"nearest:= -Well, Foundation Property Line <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED E Distance io nearest: :Welll Foundation Property Line <br /> SEEPAGE PITS El Depth -Size Nu,mbbr <br /> Foundation- Property,Line <br /> SUMPS 0 Distance to nei `Weil­ <br /> DISPOSAL PONDS 0 71 <br /> I hereby certify that I have prepared this application and that the work will be ddne 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 perfo.imance of the work for which this permit is issued, I shall not <br /> employ any person in such manner,asti5 become subject to workrinan'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 p&rsons subject to workman's compensa- <br /> tion lawi California:"- <br /> Pei <br /> The applican us� I r all u re i cons/tomplete ndwing,on r a side. <br /> 7VZ 14 ]VT <br /> 1 Signe W-0A .4 1: ill, <br /> Signed Date: <br /> A <br /> y <br /> OR DEPA <br /> L(SIE Q 1j <br /> Application Accepted by Date Area <br /> Pit or Grout lrispectior;_bY' at <br /> H3�Final Inspection by I Date <br /> V Tr <br /> Additional Comments: <br /> El Stk 466-67e1 r b Lodi 369-3621- v EI Manteca .823-7104-.., 0 Tracy 835-6385 <br /> copies to: Envilron6ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2W S*.' CA 9=1 <br /> Applicant- Return all <br /> CK <br /> FEE <br /> INFO AMOUNT DUE ' AMOUNT i-REMITTED CASH rRECEIVED BY DATE PERMIT'NO. <br /> +EH 13-24(REV.16/831 <br /> E I L <br /> H'41-25 <br />