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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES l 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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Addressoo� rva`�'"'� © City M � Lot Size <br /> Owner's Namee''' M AGt <br /> `A.A."AJ ����`� Address ( a d JA(� � IDS �' ' ' W&?0 Phone <br /> Contractor f T ` Le f <br /> Address r SV &ft11.6N IVe- License No. Zlfaf y Phone <br /> TYPE OF WELL/PUMP; „. ..=NEW WELL,0­ _WELL REPLACEMENT 0. ,rte DESTRUCTION ❑ ^^ <br /> PUMP INSTALLATION! ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 /> ❑ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ,l Public ❑ Other n Delta r Depth of Grout Seal Type of Grout <br /> Ai I Irrigation T Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter L Sealing Material Itop 501 <br /> t Depth Filler Material IBelow 50 �(} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i 1 REPAIR/ADDITION 1K DESTRUCTION I I (lJo septic system permitted it public sewer is <br /> ,it available within 200 feet.) O <br /> !NInstallation will serve: Residence_ Commercial— Other <br /> !Number of living units: Number of bedrooms <br /> haracter of soil to a depth of 3 feel: Water table depth <br /> PTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal O <br /> Distance to nearest: Wel! Foundation Property Line r� <br /> LEACHING LINE No. & Length of lines gth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth Size Number (� <br /> SUMPS L� Distance to nearest:' Well Foundation Property Line r� <br /> DISPOSAL PONDS ILI A- <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. <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 following: 1 certify that in the perf mance 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 must call for-all, quiredAns tions. Complete drawing on-reverse-side. e-, <br /> Signed X Title: N« Date: <br /> ) <br /> r FOR PART NT USE ONLY <br /> Application Accepted by �*� Date Area <br /> Pit or Grout Inspection by _Date EinaEJnspection b Date s O <br /> Additional Comments: <br /> ❑ Silk 466-6781, ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-&385 <br /> —Applicant.;,,Returr .atl copies...to:.Environmental-Health-Permit/Services_1601-E.•llazelten-Ave:;P:O­Bax-2009,-Stk.;-GA-95201---FEE -_�.---�-- <br /> INFO AMOUNT <br /> �DUE <br /> � AMOUNT'REMIITEq SH{� RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-24(REV.I/n 5) - Q Ll-/ 0 � a 1 '1 Vs <br /> EH 14-26 V i V <br />