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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> , � I <br /> 1601 E. HAZEL T ON AVE':; STOCKTON, GA <br /> Telephone (209) 466-6781 <br /> v 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 wev pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> LobAdds <br /> City��_ &e Lot Size PM <br /> �f p / <br /> me �7 � (/ D-0hi�Q1rS Address �i /�, Phone� Ha��i �1J Address l�3 7�/�/Or""4hf! LicenseNo. Phone�FLLIPUMP: NEW WELL ❑ WET REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP LNSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA i SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL.,- -OTHER PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROS AREA CON N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mantec Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy of Casing g Specifications . <br /> I Type 1"1 Public ❑ Other Cl Delta Depth o out Seal YP of Grout — <br /> . I I Irrigation pprox Depth I I Eastern Surface Seal Installed by - <br /> r <br /> Repair Work Don Type of Pump H.P. .-'"-. . State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> + Depth Filler Material (Below 50') -- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Character of sod to a depth of 3 feet: o <br /> Number of living units: � Number of bedrooms '''""'r <br /> p ' Water table depth <br /> SEPTIC TANK Type/Mfg 4 Capacity - \— No. Compartments 00 <br /> E PKG. TREATMENT PLT Metfiidd of Disposal <br /> 1 Distance to nearest: Well Foundation'= Property Line <br /> � r <br /> LEACHING LINE No. & Length of lines Total length/size {� <br /> f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS C I Depth Size Number .- - <br /> SUMPS LI Distance'to nearest: Well Foundation # Property Line <br /> DISPOSAL PONDS ❑ ` I I D <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 DiMrict. <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:"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 inspections. Complete drawing on reverse side. <br /> Signed Title: 4Gi [a Df 4*­X74-00— Date: <br /> �FR�T USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> Additional Comments: , <br /> 4 ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE AMOONT REMITTED CK RECEIVED BY DATE_ PERMIT NO. <br /> INFO <br /> ♦ EH 13.241 <br /> REV.1/+t 51 �© # .a..1 J� Y--'�� <br /> EH 14-26 G�CJ <br />