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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 1/5 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i <br /> (Complete in Triplicate) <br /> i application is <br /> I <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This app <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1962 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District- <br /> D City 4: Lot Size PM <br /> Job Address <br /> ((}} pc, Y1 Dt9ftJ1�J 1. <br /> �.>1 S adress S Phone <br /> Owner's Name �; cry_ <br /> Aess �—CQ T License Noo-q-�-a 9—S -Phone., <br /> Contractor�°�-�-_- - <br /> ddr <br /> TYPEOF WELL/PUMP: NEW WELL K WELL REPLACEMENT LJDESTRUCTION ❑ '" �`+ <br /> t PUMP-iNSTALLATI01I SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ✓bf>m"� SEWER LINES DISPOSAL FLD �' PRO(?. LINES I <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL ._] PITS/SUMPS.?:77 � <br /> 4 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5PECIFICATf S , . <br /> ten Bottom Ll W, Dia. of Well Excavation Dia.,of'Well Casing <br /> ❑ Industrial Nbp <br /> omesticlPrivate 171 travel Pack LlTracy `—Type of"Ging r r_>` Specifications <br /> C 1 Public ❑ Other Cl.Delta (' Depth of Grout Seal Type of Grout ` <br /> 4. I 1 Irrigation A.-Approx. Depth - I I Eastern/ Surlace Seal Installed by �* <br /> ` � H.P. r State Work Done <br /> Repair Work Done LJp Type of Pum. <br /> F4 Well Destruction ❑ Well Diameter _ Sealing Material (top 50'1 i 0 <br /> s Filker,M`aterial:(Below 50') <br /> Depth ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADD1TION l ] DESTRUCTION I 1 Mo septic system permitted if public sewer is r <br /> available within 200 feet.) <br /> Installation will serve: Residence, Commercial — Other _ <br /> Number of living units: Number of bedrooms <br /> II Character of soil to a depth of 3 feet: Capacity— Water table depth \�' <br /> . ype/Mfg City No. Compartments <br /> SEPTIC TANK ❑ V� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f <br /> i }}Distance to nearest: Well Foundation Pro p.ert Y Line <br /> f i <br /> LEACHING LINE ❑ 1No. & Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line } C <br /> k _ k G <br /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS -1 Distance to nearest: Well Foundation Property Line <br /> I 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 /> Home owner or licensed agent's signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall not <br /> employ any person in such mahner as to become subject to workman's compensation 1=rfTrf California." Contractor's hiring or sub-contracting signature <br /> I certifies the following: "I certify that in the pertoritlanca of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." - l <br /> The applicant m t call for all required ' spections4pirriplete drawing onVreverse sid . <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> pDate Area <br /> Application Accepted by _ <br /> Pit or Grout Inspection by D Final Inspection by Dates e / <br /> i' <br /> Additional Comments: <br /> ❑ 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 /> t <br /> CK IT <br /> FEE AMOUNT DUE AMOUNT REMITTE1) CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13-24(REV.t i x 5) <br /> EH 14-26 <br />