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APPLICATION FOR PERMIT J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <br /> i <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thi I <br /> made in com liance,with San Jo s application is <br /> p $quin County Ordinance No.549 for.sewagg or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. � <br /> Job Address / * City C Lot Size I 92 l4.-C PM ; <br /> .f <br /> Owner's Name Aeqm. .-,ad/Aj AddressPh <br /> one <br /> Contractor's Name er[. License No. s ®� - — Phone 3 6E <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wel! Casing <br /> 11 Domestic/ C1Gravel Pack © Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ""'""State"Work'Done 9 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop,50') p 1 <br /> Depth r I + Filler Material (Below 50'1 S <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONDESTRUCTION ❑ (No septic system permitted if public sewer is p, <br /> f available within 200 feet.)" _ ^ 4 <br /> Installation will serve: Residence Commercial CS ther ` O <br /> Number of living units:4-4— Number of bedrooms Y i <br /> Character of soil to a depth of 3 feet:' 1 ' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE "-r ❑ No. & Lengthiof lines y Tota! length/size <br /> FILTER BED Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS B"Depth AS t , Size f� r Number` 2— <br /> SUMPS ❑ Distance to nearest: Well r <br /> 3 �� Foundation� i Property Line <br /> DISPOSAL PONDS ❑ I, '! <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. I i <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."Contractors 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 laws of California." <br /> The applicant call r ire inspections. Complete drawing on Veverse side. <br /> Signed 'Title: 4I Date 3 <br /> rye• - x k ,- <br /> s. FOR DEPARTMENT._USE <br /> €ONLY t <br /> Application Accepted by 6 Date Area <br /> Pit r Grout Inspection by - Dat _ Final Inspection-by Date <br /> Additional Comments: ° r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104---w-LO Tracy. 835-6385 <br /> Applicant- Return all copies to: Environmental-Health-Permit/Services-1601-E:Hazelton Ave.,"P.O..•Box 2009, Stk., CA 95201 <br /> i <br /> i-� <br /> ., r. r r. <br /> �i <br /> FEE <br /> INFO I AMOUNT DUE AMOUNT REMITTED CK# t RECEIVED BY DATE( CASH PERMIT'NO.�r <br /> +EH W24(AEV.10183) <br /> Eli 14-28 <br />