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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y" <br /> 1601 E. 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. <br /> Job Address 2 AA�S City A C CIM on Lot Size PM <br /> Owner's Name }' P3V-OLJ h4 Address _ Phone . <br /> Contractor�,-)hLr r+.]NU,, Address License No. Mv9A- Phone �d S <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RE ILACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES ? T DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CgN•STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom [I Manteca Dia. of Well ExcaVition Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f l Public ❑ Other ❑ Delta Depth'of Grorit Seal Type of Grout <br /> I I Irrigation _,_Approx. Depth I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. iState Work Done <br /> 4 _ `v <br /> ,..., <br /> Well Destruction El Well Diameter, Sealing Material-ftop.50') M <br /> Depth 'rf sv. Filler Material liselow 50') t <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION PAIR/ADDITION i•1 ; DESTRUCTION I I (No septic system permitted if public sewer is 4 ' <br /> ' available within 200 feet.) (`z <br /> Installation will serve: Residence Commercial 0 er <br /> Number of living units: �_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK N4---Type/Mfg_ Capacity 00 No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method i sal <br /> Distance to nearest: Well Foundation b_ Property Line <br /> LEACHING LINE Q. A--�Length of lines Total length/size 4 <br /> FILTER BED ❑ Distance to nearest: Well=0 Foundation` s Property Line _ <br /> l <br /> SEEPAGE PITS I4-�6epth ± Size _ Number I <br /> SUMPS y" ` ❑ Distance,to nearest: Well Foundation ,.. _ Property Line <br /> DISPOSALTONDS ❑ -y <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-Di§trict.e,. -Homeownerowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalPnot <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 1 s Californi a <br /> The applican . t all r all r quire ins omplete drawing on,faverse 'de. <br /> 4 V rte, <br /> Signed X Title: �( Date: <br /> I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> _ _ Area <br /> /^) S/Pit or Grout Inspection by ate Final Inspection by Dater <br /> L/Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-5365 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEINFO AMOUNT DUE AMOUNT REMITTEDi CASH ' /R ECEIVED BY DATE ?ERMIT'3NO. `S' <br /> +.EH .24 1 REV.i i 8sl <br /> FH 14-28 <br /> 1 <br />