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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601, E. HAZE' —I ON AVE., STOCKTON, CA <br />Telephone (209) 466-67' 1 <br />PERMIT EXOIRes 1 YEAR OROM -DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made to the San Joaquin Local Health District for a permit to conSttUct and/or install the Work herein desoffbed. Thit application is <br />made in compliance with San Joaquin County Ordinance No. SO for aewaga or No, IBM for wed1pump and the Rules and Rogulatioru of the Son Joaquin <br />I" Health District, <br />%V <br />Job Address City W Sim PM <br />Joy <br />s ►Name <br />Owner'-- Address phone <br />Contractor <br />Address <br />DISTANCE TO N"Al <br />INTENDED USE <br />� i Industrial <br />-J Domastic/Privatti <br />Public <br />Irrigation <br />Repair Work Done I. I <br />Well Destruciian <br />I <br />NEW WELL 0 WELL REPLACEMENT 0 <br />• PUMP INSTALLATION 7 SYSTEM REPAIR El <br />SEPTIC TANK SEWER LINES <br />AGRICULTURE WELL 1-2,( <br />TYPE OF WELL PAORL -riwqTfit v­rttuj*,44P1 <br />0 Open Bottom <br />Cl G-Svel Pack <br />t-1 Other <br />cerise <br />-fiol4i <br />-Die. n' 'tPVadl..�ussvaitorr <br />0 Tracy Tvp-4 C-aeing- <br />0 Delta Depth. of Grout Seal <br />611slom Suir4m Seal 4tstelia�d by...._.._ <br />Typo of Puftv- r-.--. <br />Well Diameter <br />Depth <br />INSTALLATION <br />OTHER 0 <br />PROP. LINE-— <br />, <br />H�P.: StateworkDon, <br />- <br />Sealing Material fitop-5011 <br />Filler Material 1801A. W) <br />Dia, of Wall C" <br />Specifications,' <br />Type of Grout <br />(No septic system permitted it 'pubfic sewer is = <br />available within 2013 feet.) <br />Installation will serve. Residence <br />Number of living unite '-, Number of ba'drooms, <br />Character of soil to; a depth of 3 166tz' star table depth <br />SEPTIC TANK Ci Type/Mf <br />9 No. Compartments <br />PKG, TREATMENT PLT, 0 14 Method of Disposal <br />Distance to nearest: Well Property Lir* <br />L&ACHINd LINE <br />No'& Length' of 'fines <br />&A; 10c;r- <br />Total lengthisize <br />FILTER`iIED <br />U -Distance to nearest- <br />won <br />Property Line <br />SEEPAGE PITS <br />6Depth ...... .... —5j2e <br />Number—_ <br />/ SUMPS <br />> <br />Distance tv newest: <br />W-11 Found�atlonl----- Zt— Property Lkwo <br />/. DISPOSAL PONDS/ <br />0 <br />I here w certify that I have prepared this application and that the work will be done in accordance with San Jamiuln cWJnW ordinances, state Lavas, araai <br />rules and regulations of the San Joaquin Local Health District. <br />Home awrw,or licensed agent's signature cartifies the following- "I m1ify that in the performance of the work f6r*Which this permit is issuad. I sivift not <br />employ any. person in !?Iclh Maqwil to I become Matt to taws of California." OmUractCr4hifii,4 of sub-contractiirig signatufs <br />certifies the following.- the Pertornunco Of the work for 4-joh this permit is issued, I shall employ parsons subject to workman's compensa- <br />tion lawt of California <br />The applicant MAst i =Od4�WWonmpleta drawing on reverse side. <br />"' Siprrt d X <br />Title: Dow: <br />FOR DEPARTMENT USE ONLY <br />Ap} Iication Accepted U Area <br />Pit or Grout Inspection by Owe PAW Irdosaftn by <br />C/ 0 <br />Vho'nal convnerits: k <br />itk a68 8781 it Lodi 369-3621 r, Montec* M7104 0 Tracy " M&i* <br />Applicant - Return all copies to:' ErMtorim WAM Has" ParmitiSeovic" lW1 E. Hazelton Ave., P.O. Box 20M, Stk., CA 9624I <br />&4 13.2A il%ev. I, a <br />h. EH 14219 <br />rAw "'Alw". <br />