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APPLICATION FOR PERMIT A <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> h :. <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED C-e Ff�o <br /> I I (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 City �— Lot Size PM <br /> � <br /> Owner's Name •� ►` Z AIWI <br /> ddress ` v � � Phone <br /> �? � 1� <br /> Contractor� Add ess_ e� License No. '- (hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS <br /> r INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial L1 Open Bottom El Manteca Dia. of Well Excavation. Dia. f WCasing <br /> E) Domestic/Private ❑ Gravel Pack- ❑ Tracy F Type of Casing Specifications <br /> f Public fl Other ,f Delta - Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> I - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing)Material (tap 50'1 <br /> Depth "Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {.l REPAIR/ADDITION l I DESTRUCTION (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 r t <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK L1TypelMfg �"_ A'� Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ t <br /> 1 Distance to nearest: Well A -foundation Wroperty Line (� <br /> Total <br /> LEACHING LINE ❑ No. & Length of lines length/size <br /> t FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS D 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 District. <br /> ify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <br /> l 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 laws of California." <br /> The applicant must call for all required ins ctians. Complete drawing on reverse side. <br /> j Signed X Title: _ t Q Date: .` <br /> FOR DEPARTMENT USE ONLY I <br /> k Application Accepted ly <br /> " Date 'L�2 Area l <br /> ! Pit or Grout Inspection 4 �Dnlate Final Inspection by ,{n Y� I- Date Z �� <br /> Additional Comments: tom?•f ea �e-ot a-c_k� e o0-' S Le, K �. <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 Co u t d '" �/- <br /> 4 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. / <br /> INFO <br /> + EH 13-24(REV.1/R W <br /> L EH 14-26 <br />