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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ ECEIVEP! <br /> , <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED FEB 2 fi gc�Ir <br /> (Complete in Triplicate) ENVlRONMENTAL <br /> pp HEALTF�# <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the"R&lRAw0 f�pFlication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regu ationy�00 an Joaquin <br /> Local Health District. <br /> Job Address FjE RA r�� City / Lot Size PM <br /> Owner's Name .ARM/1_,r__,4106 OCC12l Address Phone <br /> Contractor ress D i+�ease No.(=!571Phone <br /> TYPE OF WELL/PUMP: NEW WELL 5_oL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA-T7IIOtNN 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES_ �, DISPOSAL_FLD.��Y"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 Well Casing <br /> )4-Domestic/Private Gravel Pack 19—Tracy Type of Casing_-. Specifications <br /> f'1 Public n Other ❑ Delta Depth of Grout Seal /W_f71'ype of Grout <br /> i I Irrigation --Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 50'1 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION f I (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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS fl Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. <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 or sub-contracting signature <br /> certifies the folloify 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 Cal <br /> The app77�w_ <br /> ll re ed ins_ ctions. Complete drawing on re arse side <br /> Signed Title: _ Date: <br /> OR DEPARTMENT USE NLY /C.Application Accepted by Date Arae <br /> Pit or Grout Inspection by Date Final Inspection by l Date 3 A>Q 9e) <br /> Additional Comments: 6-r—/,S-O <br /> ❑ Silk 466-6781 ❑ Lodi 369-3621 Manteca -7104 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 /> a=ir(4v <br /> FrrK f+c <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'No. <br /> + EH 13-24(REV.t/H51 <br /> EH t4-2e <br /> k <br />